Military Surgeons Research Articles

Surgical Ethics in the Safavid Era, 16th Century AD.

Medicine-and specifically surgery and surgical ethics-have long been part of the history of science. Surgical ethics play a pivotal role in ensuring successful outcomes and maintaining the highest standards of patient care. It includes the ethics of surgeons, the responsibility of surgeons, surgical errors, and the competence of a surgeon. Many works have been written about surgery, including during Iran's Safavid period (1501 to 1736)-a period in which a surgeon needed to have a set of moral principles in addition to practical surgical skills. One of the most valuable is Dhakhīrıh Kāmılıh, written by military surgeon Hakim Mohammad in the sixteenth and seventeenth centuries. In this work, Ḥakim Muhāmmad dedicates a chapter specifically to the topic of surgical ethics, aiming to provide moral and legal recommendations for surgeons in addition to explaining surgical techniques and methods. Some of these recommendations include improving surgical skills through observation and practical training, paying attention to hygiene to prevent the spread of infection, and giving patients hope for recovery. Dhakhīrıh Kāmılıh is a landmark text in the history of surgical ethics.

Operative Efficiency in Military Total Joint Arthroplasty Is Superior at an External Resource Sharing Agreement Facility as Compared to a Military Treatment Facility.

Surgeries within the Military Health System (MHS) are often performed by military physicians at External Resource Sharing Agreement (ERSA) hospitals to offload the operative demand at Military Treatment Facilities (MTFs). These agreements allow physicians flexibility in selecting where to treat military service members and other TRICARE beneficiaries. However, there is a paucity of military orthopedic literature comparing ERSA hospitals and MTFs. The objective of this study is to compare operative volume, efficiency, and orthopedic resident operative experience between an ERSA hospital and an MTF in military arthroplasty. A retrospective chart review was conducted for all surgeries performed between October 1, 2022 and July 31, 2023 by three military arthroplasty-trained surgeons at an MTF and two associated ERSA hospitals (denoted as ERSA-A and ERSA-B). Details recorded include spinal time-out time, spinal end time, in-room time, case start time, case stop time, and out-of-room time. These were used to calculate the total time in room (out-of-room time minus in-room time), case time (case stop time minus case start time), extra time in room (total time in room minus case time), and time between cases (in-room time minus out-of-room time of previous case). Lastly, we compared the average daily case volume and operative time between the facilities. Only primary joint replacements with properly documented time stamps were included in the efficiency analysis. Continuous variables were assessed for normality by the Shapiro-Wilk test. Non-normal data are presented as the median and interquartile range (IQR) and were analyzed using the Mann-Whitney U test (for two group comparisons) or the Kruskal-Wallis test (three or more groups) with Dwass-Steel-Chritchlow-Fligner pairwise comparisons. The associations between categorical variables were analyzed using the chi-squared test. Significance was set to P < .05. Statistical analyses were performed using SAS version 9.4 (Statistical Analysis Software, Cary, NC, USA). This study was classified as exempt human subjects research by the authors' institutional review board. Average daily case volume was significantly higher at both ERSA-A (median of 3, IQR 2-4, P < .001) and ERSA-B (median of 2, IQR 2-3, P = .0075) compared to the MTF (median of 2, IQR 1-2). This translated to residents operating for a median of 270 minutes (IQR 170-398, n = 25 OR days) each operative day at ERSA-A compared to 234 minutes (IQR 131-304, n = 91 OR days) when at the MTF, which was not a significant difference (P = .21). Median case time was 26.5 minutes lower (P < .001), extra time in room was 5 minutes lower (P < .001), and time between cases was 67 minutes lower (P < .001) in the ERSA group as compared to the MTF group. Utilizing ERSAs can improve patient throughput and operative efficiency, which in turn enhances orthopedic resident operative experience. These findings suggest that the MHS should seek ways to improve operative efficiency at MTFs. Expanding ERSA contracts to reach a broader portion of TRICARE beneficiaries, including patients over 65 years of age and those with supplemental insurance, who are currently ineligible, should also be explored.

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

Accuracy and Safety of Freehand Placement of Upper Thoracic Pedicle Screws Supported Solely by Anteroposterior, i.e., Frontal, X-Ray Fluoroscopy (C-Arm): Technical Note Including 23 Patients

IntroductionThe biomechanical resistance and the surgical morbidity of spinal posterior pedicle screw fixation relies on the intraosseous position of the implants. Upper thoracic pedicle screws are particularly demanding given their convergence and thin character. We present our experience as military surgeons of free hand placement of upper thoracic pedicle screws supported by antero-posterior, i.e. frontal X-ray fluoroscopy solely. Materials and methodsMonocentric retrospective analysis at Sainte-Anne Military Teaching Hospital between 2017 and 2024 of patients operated on using upper thoracic pedicle screws (levels T1 to T5) using antero-posterior fluoroscopy solely. Results23 patients were included (mean age 59, male/female 3.6), 16 traumas and 7 neoplastic lesions), with 15 cervicothoracic junction fixation and 8 upper thoracic spine surgeries. 124 screws were inserted (T1 to T5). 85% (106/124) were graded 0 (Gertzbein-Robbins scale) whereas 14.5% (18/124) displayed some degree of misplacement (grade 1 to 3): all the T1 screws (22/22) were accurately placed compared to 83% (20/24) of T2 screws, 88% (30/34) of T3 screws, 85% (17/20) of T4 screws, and finally 71% (17/24) of T5 screws, without any clinical consequences. There were 3 surgical revisions (1 asymptomatic misplaced screw, 2 mechanical failures in trauma). Last, 92.7% (n=51/55) of the screws inserted during working hours were accurately placed compared to 79.7% (n=55/69) during after-hours surgeries (p=0.039) ConclusionClinically speaking, placement of upper thoracic pedicle screws using antero-posterior fluoroscopy solely appears safe. The surgical technique is simple enough to be used in strained resources settings such as a mobile field surgical team.

Perceptions of general surgery residents at military treatment facilities: Excellent training with crisis of confidence.

The declining operative volume at Military Treatment Facilities (MTFs) has resulted in Program Directors finding alternate civilian sites for resident rotations. The continued shift away from MTFs for surgical training is likely to have unintended negative consequences. An anonymous survey was generated and sent to the program directors of military general surgery training programs for distribution to their residents. A total of 42 residents responded (response rate 21%) with adequate representation from all PGY years. Ninety-five percent of residents believed that their programs provided the training needed to be a competent general surgeon. However, when asked about career choices, only 30.9% reported being likely/extremely likely to remain in the military beyond their initial service obligation, while 54.7% reported that it was unlikely/extremely unlikely and 19% reported uncertainty. Eighty-eight percent reported that decreasing MTF surgical volume directly influenced their decision to stay in the military, and half of respondents regretted joining the military. When asked to assess their confidence in the military to provide opportunities for skill sustainment as a staff surgeon, 90.4% were not confident or were neutral. Although military surgical residents have a generally positive perception of their surgical training, they also lack confidence in their future military surgical careers. Our findings suggest that declining MTF surgical volume will likely negatively impact long-term retention of military surgeons and may negatively impact force generation for Operational Commander. Prognostic and Epidemiological, Level IV.

What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment.

Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.

Exploring how military culture shapes veterans' perception of aortic aneurysm repair: A qualitative study.

Veterans represent a distinct cultural group whose perceptions of illness and treatment are influenced by military culture. The study explores how prior military service shapes Veterans' assumptions and behaviors in the setting of aneurysm repair surgery. We conducted content and thematic analysis of a case series of 10 transcripts from telephone interviews with older (76.7 ± 4.3 years) African American and White male Veterans now residing in the Southern U.S. who underwent open or endovascular aneurysm surgery at Veterans Affairs Medical Centers or university affiliates between 2004 and2019. Throughout the continuum of care, Veterans described deferring to authority and not questioning provider's decisions ["I just can't make a judgment on that, because I'm not a doctor"]. Veterans valued commitment and articulated pride in keeping logistically challenging surveillance appointments [I always took them very seriously. . . If I'm scheduled for something by the doctor, I always make it."]. The routine structure of VA care aligned with Veterans military experiences, facilitating compliance with doctor's orders. However, procedural deviations in VA care were disconcerting for patients ["They haven't reached out to me in at least three years, since my surgery; I was being seen once a year and then all of a sudden, they just quit."]. While Veterans praised VA care, they exhibited sensitivity to signs of untoward treatment from clinical and support staff "…my surgeon, he never talked to me before, nor after, no anytime…I thought that maybe that wasn't right". Military culture embodies rank, order, and respect, and remains a source of strength and stability for Veterans in their medical care late in life. Cultural competency about how military service has shaped Veterans' expectations can enhance providers' awareness of patients' military mindsets and inform surgeons' efforts to engage Veterans in shared decision making.

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study

BackgroundNon-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. MethodsData were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. ResultsWe included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). ConclusionThe French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

Островки милосердия. Российские медики во время военных действий на Северном Кавказе в 1990 — начале 2000-х гг

At the turn of the XX–XXI centuries, Russia had to conduct active military operations twice to suppress the hotbed of separatism, crime and terrorism in the North Caucasus. Serious military medicine forces had to be involved. Meanwhile, the participation of medical professionals in two Chechen operations is still on the periphery of attention of domestic researchers. In the 1990s and early 2000s, the Russian mass media wrote that military doctors were helping wounded and sick servicemen of the federal troops directly on the front line and in rear hospitals, often informed the general public about maintaining the mental health of recent front-line soldiers, and also never ignored the assistance to the civilian population (women, the elderly, children) of the Chechen Republic. Some press publications described the most successful and complex operations performed by Russian military surgeons. In many publications of those years, you can also find reports about the doctors who distinguished themselves the most during the active hostilities and were awarded high state awards, including the Gold Star of the Hero of the Russian Federation. The practical activities of Russian doctors in the North Caucasus in the 1990s and early 2000s resulted not only in the saving of the lives of the vast majority of wounded soldiers, but also in restoration of the Chechen health system, prevention of epidemics and successful fight against numerous infectious diseases.

Investigating Research Hotspots of Combat-related Spinal Injuries: A 30-year Bibliometric Analysis Study.

Spinal cord injuries often lead to significant motor and sensory deficits, as well as autonomic dysfunction. Compared with normal spinal injuries, combat-related spinal injuries (CRSIs) are usually more complex and challenging to treat because of multiple traumas, firing-line treatments, and arduous initial treatments on a battlefield. Yet numerous issues remain unresolved about clinical treatment and scientific research. The enhancement of CRSI diagnosis and treatment quality by military surgeons and nurses is imperative. The objective of this study is to identify the frontiers, hotspots, and trends among recent research, summarize the development process of clinical trials, and visualize them systematically. We collected publications from CRSI based on the Core Collection of Web of Science for 30 years from January 1, 1993 to May 1, 2023.Visualizations of the knowledge maps were produced using VOSviewer and CiteSpace software. We examined annual trends of publications and distribution patterns, the number of publications, as well as the research hotspots. Among 201 documents, it was found that there was a stable upward trend in publications. There were 2 rapid growth stages during the 30 years. Among all countries, the USA contributed the most publications, along with the highest influence and the most international cooperation. Military Medicine was the journal of the maximum publications, whereas the Spine journal was the most influential one. Keyword co-occurrence analysis and trend topics analysis revealed that these articles focused 5 distinct categories for CRSI. As the first bibliometric study focused on CRSI, we demonstrated the evolution of the field and provided future research directions. We summarized the hotspots and 5 clusters published. This would serve as a useful guide for clinicians and scientists regarding CRSI global impacts.

Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness.

Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric. In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean. The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically. The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan.

All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL). The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care. Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members. Prognostic and Epidemiological; Level IV.

Bogdan N. Kotiv — surgeon, professor, general of medicine (on the 60th anniversary of his birth)

March 14, 2024, marked the 60th anniversary of Bogdan N. Kotiv, the Deputy Head of the Military Medical Academy named after S.M. Kirov for clinical work, abnormal chief surgeon of the Academy, Honorary Doctor of the Russian Federation, Doctor of Medical Sciences, Professor, and Major General of the Medical Service. After graduating from the academy, B.N. Kotiv served in the Transcaucasian Military District as a leading surgeon in a separate medical battalion. In 1988, a young military surgeon participated in the provision of assistance to victims of the earthquake in the city of Spitak (Armenia) and received the first experience in providing medical care in military field conditions. In 1990, B.N. Kotiv entered the adjunct school at the Department of General Surgery, and in 1993, he successfully defended his dissertations for the degree of candidate of medical sciences. In 1998, the dissertation for the Doctor of Medical Sciences degree was brilliantly defended. In 2006, Bogdan N. Kotiv headed the Department of Hospital Surgery. When it was going through difficult times, a reorganization of the educational process occurred. Bogdan N. carefully preserved the traditions of teaching thoracic surgery and actively introduced the experience of modern complex surgical interventions into the educational process, including on the abdominal organs. The surgical school of the Department of Hospital Surgery rapidly took a leading position. In 2013, B.N. Kotiv was appointed the Deputy Head of the Academy for Academic and Scientific Work. Since 2021, Bogdan N. Kotiv has been the Deputy Head of the Academy for Clinical Work. He controlled and coordinated the clinical base of the academy, organized interactions with military hospitals throughout the country, and often went on business trips. At the beginning of a special military operation, a colossal responsibility fell on his shoulders. There was a need to quickly solve the permanently emerging problems of organizing the provision of medical care to the wounded in the conditions of the Academy clinics. With his direct participation, the clinical base was redesigned, its bed capacity was expanded, and new technologies for providing specialized medical care to the wounded, sick, and injured were introduced. For several generations of surgeons, Bogdan N. has been a wise mentor and role model. Under the leadership of Bogdan N. Kotiv, the range of scientific research conducted at the academy has significantly expanded. The fundamental directions of medicine for the study of the molecular and cellular foundations of combat lesions and cellular and tissue engineering technologies have received new development, and multidisciplinary scientific research is being conducted regarding the regenerative abilities of the liver.

Sustaining Military Surgeons and the Joint Trauma System: Current Efforts, Unique Challenges, and Proposed Strategies in an Era of Global Uncertainty.

Mini abstract US military assets have been integral to the response to global pandemics, natural disasters, civilian casualties, and combat care. Strategies are being implemented to strengthen the military health care system and curtail the erosion of relevant surgical skills and knowledge during periods of low combat intensity. However, additional challenges remain. We describe these strategies and obstacles but also explore potential solutions that may strengthen the readiness of military surgeons and combat trauma teams.

Telemedicine for Potential Application in Austere Military Environments: Neurosurgical Support for a Decompressive Craniectomy.

The main goal of this study was to assess the feasibility of a head-mounted display (HMD) providing telemedicine neurosurgical support during a decompressive craniectomy by a military surgeon who is isolated from readily available neurosurgical care. The secondary aim was to assess the usability perceived by the military surgeon and to evaluate technical aspects of the head-mounted display. After a standard concise lecture, 10 military surgeons performed a decompressive craniectomy on a AnubiFiX-embalmed post-mortem human head. Seven military surgeons used a HMD to receive telemedicine neurosurgical support. In the control group, three military surgeons performed a decompressive craniectomy without guidance. The performance of the decompressive craniectomy was evaluated qualitatively by the supervising neurosurgeon and quantified with the surgeons' operative performance tool. The military surgeons rated the usability of the HMD with the telehealth usability questionnaire. All military surgeons performed a decompressive craniectomy adequately directly after a standard concise lecture. The HMD was used to discuss potential errors and reconfirmed essential steps. The military surgeons were very satisfied with the HMD providing telemedicine neurosurgical support. Military surgeons in the control group were faster. The HMD showed no hard technical errors. It is feasible to provide telemedicine neurosurgical support with a HMD during a decompressive craniectomy performed by a non-neurosurgically trained military surgeon. All military surgeons showed competence in performing a decompressive craniectomy after receiving a standardized concise lecture. The use of a HMD clearly demonstrated the potential to improve the quality of these neurosurgical procedures performed by military surgeons.

Practice Patterns of Pancreatic Surgery Within the Military.

Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.

Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership

IntroductionMedical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian...

Forging alliances: examining civil-military partnerships and their impact on war-time casualty care in Sri Lanka

Over the course of the 26-year civil war in Sri Lanka between the Liberation Tigers of Tamil Eelam (LTTE) and the government forces, LTTE’s ‘military’ capacity and strategy evolved from guerrilla-type ambushes using landmines to semi-conventional warfare with light arms and eventually to heavy artillery and improvised explosive devices. This evolution required both military and civil surgeons to enhance their knowledge and skills in managing high-energy war wounds to handle the large number of casualties admitted to health institutions. The Sri Lanka Medical Corps (SLMC) had been meticulously organized into echelons of care with graded capacity and capability to medivac battle injured personnel from point of injury to definitive care facilities. All injured personnel eventually found their way to Colombo Army Hospital and Ragama Rehabilitation Hospital for comprehensive rehabilitation. The civil war in Sri Lanka presented a significant influx of war-related injuries, demanding the creation of a comprehensive system seamlessly integrating both military and civilian elements. With a decade of peace, accompanied by shifts in injury epidemiology, the evolving landscape has mandated the exploration of innovative strategies to sustain and enhance the surgical skill-base for both military and civilian casualty care.

The Rise and Fall of the Thoracoabdominal Incision in Urological Oncology

Objectives The thoraco-abdominal incision (TAI) has been used to provide maximal surgical exposure in the management of combined supra- and infra-diaphragmatic pathologic processes such as levels III or IV thrombi of the IVC. The TAI was once a cornerstone of urological oncology but is becoming increasingly uncommon in the era of robotic approaches to the renal hilum, suprahilar lymph node chain, and minimal access chest surgery to the supradiaphragmatic IVC. We wished to explore the complete history of the TAI, from first description to its height of popularity and its current utilization by contemporary urologic oncologists. Methods Primary source material included an interview with Donald Skinner, an early proponent of the TAI. We conducted a novel survey of active urologists in contemporary practice to investigate the usage of the TAI in practice. We reviewed documents from the Second Auxiliary Surgical Group (SASG) from 1941-1944; reports by military surgeon DF Marshall, recognized as performing the first TAI for a genitourinary indication during World War II; and records of the 8055th US Army (MASH) Unit in Korea, credited with improving the battlefield usage of the TAI; and secondary sources from the AUA’s WP Didusch Archive, PubMed, and Googlescholar. Results The thoraco-abdominal incision (TAI) can originally be traced back to French civilian usage in the latter 19th century, but the TAI was not adopted for battlefield trauma surgery until the Second World War. The safety and effectivness of the TAI increased greatly during the Korean War with teaching, organized outcomes analyses, and improvement efforts. Trauma indications during these conflicts allowed for later adoption in the field of urologic oncology due to the incision’s excellent exposure and became the hallmark of at least one fellowship in urologic oncology. Fewer than 15% of surveyed urologists in the contemporary era have used the TAI in the past 5 years. Conclusions The thoracoabdominal incision’s later adoption by the civilian population is a testament to the ingenuity and resourcefulness of military surgeons in the former part of the twentieth century. Their contributions should not be forgotten as urological surgery moves towards minimally invasive approach.

Academician of the Russian Academy of Sciences, Professor Y.L. Shevchenko as a person and his attitude to dentistry and maxillofacial surgery

The purpose of the study is to share personal impressions about the prominent organizer of military and practical healthcare, former Minister of Health of the Russian Federation Professor Y.L. Shevchenko, as well as his attitude and contribution to dentistry and maxillofacial surgery.&#x0D; Material and methods. When writing this article, we used exclusively our personal memories from communication with Academician of the Russian Academy of Sciences, Professor Y.L. Shevchenko.&#x0D; Results. You can read about the professional and social activities of Academician of the Russian Academy of Sciences, Honored Scientist of the Russian Federation, laureate of the State Prize of Russia, Professor, Colonel-General of the medical service, retired Yuri Leonidovich Shevchenko in many publications. Y.L. Shevchenko made a major contribution to the creation of a territorial health system (practical and military), focusing on aspects of economics and health management, as well as in the formation of the national health insurance system and much more. This article highlights the personal qualities of this respected scientist, clinician, organizer of military and practical healthcare, as well as a public figure, emphasizes his humanity, respect for teachers and subordinates, as well as dedication to his work, his understanding and importance of the tasks facing dentistry and maxillofacial surgery. The contribution of Y.L. Shevchenko to dentistry was noted, as well as the perpetuation of the memory of outstanding military maxillofacial surgeons and dentists.&#x0D; Conclusions. Personal communication with the academician of the Russian Academy of Sciences, Professor Y.L. Shevchenko, has always been pleasant and productive for the author. Such Teachers as Professor Y.L. Shevchenko can be considered the STANDARD OF MAN AND HUMANITY.