General Surgery Operations Research Articles

EGS SO09 - Documentation Of Mortality While Consenting For Major Emergency Operation In General Surgery : Are We Informing Patients Or Just Impressing NELA? A Three-Cycle Clinical Audit

Abstract Background Approximately 30,000 to 50,000 emergency laparotomies are performed annually in the United Kingdom (UK), with an in-hospital mortality rate of 9.2%. The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report from 2011 recommends that the risk of mortality should be explicitly discussed with patients and clearly documented on consent forms and in medical records. The purpose of our audit was to assess the frequency of documenting the risk of mortality in consent forms and to evaluate the reporting of corresponding discussions in the medical records of patients undergoing major emergency general surgical operations. Method Patients were identified from our National Emergency Laparotomy Audit (NELA) database, and data was collected retrospectively from our online medical records. We included procedures from NELA performed on patients aged 16 and older who had the capacity to give consent. The first audit cycle took place from April to June 2021, the second from March to May 2022, and the third from March to May 2023. The results of the first cycle revealed gaps in documentation, leading to the implementation of periodic reminders for surgeons during meetings and the use of posters to reinforce best practices. Results The 1st cycle included 40 cases, with 93% documented mortality in NELA, 40% in consent forms, and 35% documented discussion about mortality in medical notes. The 2nd cycle reviewed 38 cases, showing 92% documented mortality in NELA, 71% in the consent forms, and 42% of documented discussion about mortality in the medical notes. The 3rd cycle assessed 32 cases, with 90% documented mortality in NELA, 92% in consent forms, and 51% in the medical notes. The improvement in documentation of the risk of death in the consent forms was statistically significant across all three cycles (p < 0.0001). Conclusion The three audit cycles demonstrated that implementing periodic reminders and posters for surgeons significantly improved the documentation of mortality risk. Documentation rates in consent forms increased from 40% in the first cycle to 92% by the third cycle, and in medical notes from 35% to 51%. These interventions effectively enhanced compliance with best practices. However, continuous effort is essential to maintain this improved practice. Regular monitoring, ongoing education, and reinforcement strategies should be employed to ensure that the documentation standards remain high and continue to improve patient care and safety.

EGS SO26 - Back Under the Knife: Unveiling the Fate of non-trauma Patients Returning to the Emergency Theatre

Abstract Background Offering a planned or unplanned second operation in emergency general surgery is not uncommon. However, there is a scarcity of data in this context. This study aims to evaluate the outcomes of patients who were offered two emergency operations to those who required one operation, focusing on complications, increased level of care at discharge and mortality rates. Method We identified those patients who underwent planned and unplanned revisits to the emergency theatre between July 2020 and July 2023. Inclusion criteria were consistent with the established UK National Emergency Laparotomy Audit (NELA at our centre over three years.. We examined demographics, ASA (American Society of Anesthesiologists) classification, indications and outcomes in terms of complications, increased post-operative care levels and mortality rates. Results 390 patients (89.3%) required one operation (1OP) and 47 (10.7%)patients underwent two operations (2OP) . The median age was 70 years for 1OP and 71 years for 2OP, with a male-to-female ratio of 192:198 in 1OPG and 22:25 in 2OP. The median ASA score (2 vs. 3), median frailty score (3 vs. 4) and the median Clavien-Dindo classification (2 vs. 4), and length of stay in days (12 vs. 21) were significantly higher for the 2OP. The increase in the level of care at discharge (30.6% vs. 59%) and the mortality (7.4% vs. 32%) were higher in the 2OP. Conclusion Our study shows that non-trauma patients requiring a second emergency operation face significantly worse outcomes compared to those undergoing only one surgery. Specifically, the group needing two operations experienced higher rates of complications, increased levels of post-operative care, and significantly higher mortality rates. These findings underscore the critical need for close monitoring and a multidisciplinary approach perioperatively. Moreover, these insights can help provide patients and their families with informed decision-making regarding the potential risks and benefits of additional surgical interventions. A prospective multicentre study would be valuable in providing further insights into this subgroup of patients.

Management Of Inguinal Hernias In Adults In Mulongo: A Local Anesthesia Approach

Introduction: Inguinal hernia, passage through the transversalis fascia of a peritoneal diverticulum, is a common condition often requiring surgical intervention. It represents one of the most frequent reasons for consultation in surgery, with a worldwide incidence estimated at 4.6% of the population. Objective: Describe the epidemiological, clinical aspects and therapeutic modalities of sublocal hernia repair of inguinal hernias in adults in the territory of Mulongo. Materials and Methods: This descriptive cross-sectional and prospective study was conducted during a campaign of free general surgery operations in Mulongo, Haut-Lomami, DRC, between June 1, 2021 and December 31, 2021. Local anesthesia with xylocaine was used. The parameters evaluated were frequency, age, sex, anatomoclinical type, type of anesthesia and postoperative evolution. Results :A total of 162 patients were included. The mean age was 41.5 years (range: 18-70). There were 90.7% men, the sex ratio was 9.8. The hernia was simple in 95.6% of cases and located on the right in 50% of cases. In 4.4% of cases the hernia was operated on urgently (strangulated and engorged and painful). Postoperative pain was the most common postoperative complication found in 54.9% of cases. Conclusion: The management of inguinal hernias in adults in Mulongo is often carried out under local anesthesia, due to the high prevalence of this pathology in the professional context of patients. Inguinal hernia thus remains a significant problem in this region, justifying adapted approaches such as local anesthesia

Trends in general surgeon operative practice patterns in a modern cohort

IntroductionAnalyzing general surgeons’ operative case mix can provide an update on contemporary practice patterns and inform pragmatic residency training. MethodsWe performed a retrospective cohort study of general surgeons in Florida, Iowa, and Maryland, 2016–2020. Cases were identified using billing codes. The Cochran-Armitage test of trends was used to evaluate the proportion of practice devoted to specific case types and operative setting over time. ResultsGeneral surgeons (n ​= ​1300) performed 1,287,745 cases. The mean (±SD) annual volume per surgeon for all procedures was 356 (±250), with 198 (±152) general surgery operations, 57 (±142) endoscopic procedures, and 101 (±109) other cases. On average, surgeons operated on 7.1 (±2.6) different organ systems. Trends toward a lower proportion of general surgery operations, and a greater proportion of subspecialty procedures and surgery in the outpatient setting over time were demonstrated (p ​< ​0.001). ConclusionThe practice pattern of the general surgeon continues to be heterogeneous, reflecting the persistent need for a broad training paradigm that permits specialization.

Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma: A Longitudinal Study.

Single-institution retrospective financial analysis. Trauma care is consistently linked to inadequate reimbursement, posing a significant financial burden for large trauma centers. Data show that declining Medicare reimbursement rates have indirectly led to declining payment for all procedures covered by insurance. The goals of this study are to investigate the opportunity cost associated with contemporary surgical management of CMF trauma at our institution and to evaluate longitudinal financial trends. Patients with operative facial fractures between 2015 and 2022 at Duke University Medical Center were included and compared to patients undergoing general otolaryngology, plastic surgery and oral surgery operations in the same period. Procedural codes, payor type, charges billed, collections, relative value units (RVUs) and other financial data were obtained and analyzed among the 2 patient populations. Comparative analysis was performed to assess the financial trends in data reported previously from 2007-2015. The collection rate at Duke University Medical Center for operatively managed CMF fractures remains significantly lower than non-CMF counterparts. Interestingly, the collection rate gap between CMF and non-CMF surgeries has narrowed when comparing to the data from 2007-2013. This is largely due to a decrease in collection rates for non-CMF procedures from 29.61% (2007-2013) to 26.57% (2015-2022) [P = 0.0001] and an increase in collection rates for CMF procedures from 17.25% (2007-2013) to 18.05% (2015-2022) [P = 0.0001]. Despite a slight improvement of the gap in reimbursement rates for CMF and non-CMF surgeries over the last several years, trauma care continues to have a negative financial impact on health care institutions.

Rise of the robots: implementing robotic surgery into the acute care surgery practice.

Acute Care Surgery (ACS) admissions and procedures are substantially increasing. ACS disproportionally accounts for a majority of morbidity and mortality among surgical patients. Minimally invasive techniques are associated with improved outcomes and shorter hospital length of stay within the ACS population. While laparoscopy is widespread, ACS surgeons have been slower to adopt the use of robotics. We aimed to evaluate the feasibility of incorporating robotic surgery within ACS practice. Robotic General Surgery operations performed by 8 Acute Care Surgeons from 5 local facilities within a large integrated healthcare system were queried over a 15 month period. Patients who underwent emergent, urgent, sub-acute, and elective robotic operations by ACS staff were identified. Demographics collected included age, gender, BMI, and ASA score. Outcomes recorded included procedure classification, total supply and implant charges (TSI), conversion to open, hospital length of stay (LOS), 30 day readmission, and 30 day mortality. Of 200 operations, the most common were Cholecystectomy (43.5%), Inguinal hernia repair (26.0%), Ventral hernia repair (18.0%), Appendectomy (5.0%), and Sigmoid Colectomy (3.5%). The median (± std dev) age was 48 ± 16.66years and BMI was 29.9 ± 8.79kg/m2. 46% of cases were sub-acute (n = 92), 33.5% were elective (n = 67), 14% were emergent (n = 28), and 6.5% were urgent (n = 13). Most patients were ASA 2 (107, 46.1%) or ASA 3 (71, 45.9%). The median (IQR) TSI and LOS were $1,770 (889.50) USD and 0.1 (0.9) days. Forty-one inpatient procedures were performed. Median LOS was 3days and expected LOS was 3.1days (O:E = 0.96). Five patients were readmitted within 30days, and there were no deaths within 30days. Robotic techniques may be safely implemented by ACS surgeons, potentially benefitting both patient and surgeon. LOS was similar between laparoscopic and robotic cases and only two cases required conversion to an open procedure. Next steps include a multi-center prospective trial comparing robotic to laparoscopic cases.

FP8.9 - Surgical Synergy: Rethinking waste for a greener tomorrow in General Surgery

Abstract Aims Every year in the UK, the NHS sends approximately 156,000 tonnes of clinical waste for processing via high temperature incineration or other treatments, and then to landfill sites. Majority of the waste produced by hospitals comes from the operating theatres (OTs). In this study, we aim to assess the current implementation of waste management strategies at an NHS district general hospital (DGH) in general surgery. We have investigated a variety of cases and have surveyed the volume of waste produced. Methods We observed elective and emergency general surgery cases across 2 weeks. For each case, we weighed the waste produced- both recyclable and non-recyclable (clinical). Results This study included four umbilical hernia repairs, two right hemicolectomies, one examination of rectum under anaesthesia with seton insertion and three laparoscopic cholecystectomies. Across the operations, the average total waste produced was 5.9kg. The average clinical waste and recyclable waste was 4.7kg and 1.2kg, respectively. Additionally, a significant proportion of non-infectious recyclable waste was incorrectly placed into the clinical waste bin. Conclusion On average 5.9kg of waste is produced after a general surgery operation. Most of this waste is clinical and not recycled. However, the clinical waste can be cut down by appropriate waste segregation, thus reducing the impact on the environment as well as reducing the cost of incineration.

EP369 - Abscess as unplanned returns to theatres in Emergency General Surgery

Abstract Aim Unplanned Return to Theatre (URTT) impacts patient care along with financial and legal implications on hospital resources. This can be reduced by identifying the contributing factors and measures taken to rectify them. This study was conducted at District General Hospital in England, aims to review the incidence of URTT in Emergency General Surgery and identify the preventable causes. Method A retrospective review was conducted for all Emergency General Surgical Procedures done between 1st January 2019 to 31st January 2021. The data was obtained from the Hospital data softwares Fusion and Bluespier, in addition to the paper notes. The operations were classified as index operation, followed by the number of returns and the indication for the URTT. Result A total number of 1578 emergency general surgery operations were performed during a period of 25 months (Jan 2019 to January 2021). The unplanned return to theatres (URTT) were 85 (5.3%), with a 90-day mortality of 16. Among these, 29.4% (25) URTT were abscess. The major reason (66%) for this URRT was inadequate drainage requiring redo/debridement. The other reasons were laying open of fistula/seton placement (30%) and stoma formation (4%). Level of operating surgeon was Consultant (8%), Registrar/Core Trainee (64%) and missing data (28%). Conclusion Abscess is a frequently performed operation in Emergency General Surgery. Knowledge of anatomy with adequate incision ensuring good drainage of the abscess can prevent URTT for abscess, improving patient outcomes and cost benefits.

Disparities in outpatient rural cholecystectomy outcomes

BackgroundPrevious studies showed comparable outcomes for common in-patient general surgery operations, but it is unknown if this extends to outpatient operations. Our aim was to compare outpatient cholecystectomy outcomes between rural and urban hospitals. MethodsA retrospective cohort analysis was done using the Nationwide Ambulatory Surgery Sample for patients 20-years-and-older undergoing cholecystectomy between 2016 and 2018 ​at rural and urban hospitals. Survey-weighted multivariable regression analysis was performed with primary outcomes including use-of-laparoscopy, complications, and patient discharge disposition. ResultsThe most common indication for operation was cholecystitis in both hospital settings. On multivariable analysis, rural hospitals were associated with higher transfers to short-term hospitals (adjusted odds ratio [aOR] 2.40, 95%CI 1.61-3.58, p ​< ​0.01) and complications (aOR 1.39, 95%CI 1.11-1.75, p ​< ​0.01). No difference was detected with laparoscopy (aOR 1.93, 95%CI 0.73-5.13, p ​= ​0.19), routine discharge (aOR 1.50, 95%C I0.91-2.45, p ​= ​0.11), or mortality (aOR 3.23, 95%CI 0.10–100.0, p ​= ​0.51). ConclusionsPatients cared for at rural hospitals were more likely to be transferred to short-term hospitals and have higher complications. No differences were detected in laparoscopy, routine discharge or mortality.

818 Acute Appendicitis: Why the Wait? – a Retrospective Analysis of Timings Associated with the Most Common Emergency General Surgery Operation

818 Acute Appendicitis: Why the Wait? – a Retrospective Analysis of Timings Associated with the Most Common Emergency General Surgery Operation

592 Standardising General Surgery Operation Notes According to Royal College of Surgeons England Guidelines

592 Standardising General Surgery Operation Notes According to Royal College of Surgeons England Guidelines

National trends and outcomes of robotic emergency general surgery in the United States

BackgroundRobot-assisted surgery has seen exponential adoption over the last decade. Although the safety and efficacy of robotic surgery in the elective setting have been demonstrated, data regarding robotic emergency general surgery remains sparse. MethodsAll adults undergoing non-elective appendectomy, cholecystectomy, small or large bowel resection, perforated ulcer repair, or lysis of adhesions were identified in the 2008 to 2020 National Inpatient Sample. Temporal trends were analyzed using a rank-based, non-parametric test developed by Cuzick (nptrend). Using laparoscopy as a reference, multivariable regressions were used to evaluate the association between robotic techniques and in-hospital mortality, major complications, and resource use for each emergency general surgery operation. ResultsOf an estimated 4,040,555 patients undergoing emergency general surgery, 65,853 (1.6%) were performed using robotic techniques. The robotic proportion of minimally invasive emergency general surgery increased significantly overall, with the largest growth seen in robot-assisted large bowel resections and perforated ulcer repairs. After adjustment for various patient and hospital-level factors, robot-assisted large bowel resection (adjusted odds ratio 0.73, 95% confidence interval 0.58–0.91) and cholecystectomy (adjusted odds ratio 0.66, 95% confidence interval 0.55–0.81) were associated with significantly reduced odds of perioperative blood transfusion compared to traditional laparoscopy. Although robotic techniques were associated with modest reductions in postoperative length of stay, costs were uniformly higher by increments of up to $4,900. ConclusionRobotic surgery appears to be a safe and effective adjunct to laparoscopy in minimally invasive emergency general surgery, although comparable cost-effectiveness has yet to be realized. Increasing use of robotic techniques in emergency general surgery may be attributable in part to reduced complications, including blood loss, in certain operative contexts.

Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery

BackgroundRecent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality. MethodsAdults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume. ResultsOf an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12–1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume. ConclusionWe note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.

Association of socioeconomic vulnerability with outcomes after emergency general surgery

PurposeSocial determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied. MethodsAll adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes. ResultsOf ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55–77] vs 58 years [41–70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3–5] vs 2 [1–3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58–1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98–2.06). Vulnerable also experienced a greater duration of stay (β+4.64 days, confidence interval +4.54–4.74) and hospitalization costs (β+$1,360, confidence interval +980–1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38–2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26–1.32). ConclusionSocioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.

Study of Outcome of Diathermic Incision Cautery more than 5 cms in General and Urologic Surgery Operations

Introduction: Cutting diathermy is a more recent alternative to scalpel for surgical incisions. Its use was limited due to fear of increased risk of infection, impair healing and decrease cosmesis. However, recent studies suggest otherwise, claiming that diathermy may offer potential advantages with respect to blood loss, incision time and post-operative pain. The aim of this study was thus to evaluate the outcome of diathermic incision in terms of healing, post-op pain and scar characteristics in operations with incisions more than 5 cm in size. Materials &amp; Methods: A hospital based observational study included 182 cases scheduled to undergo surgery requiring more than approximately 5 cm of incision. Cases were operated by surgeons who have a minimum of 3 years of experience. Incision time, wound healing, post-op pain and scar characteristics were noted at discharge and follow up at 7th and 30th day. Results: Mean incision time was 24.5 seconds with almost half of the cases (48.9%) had incision time between 20-30 seconds. A significant improvement was observed in all cases regarding mean Southampton wound score and pain score from day of discharge till day 30th of follow up. A significant improvement was also observed in patient and observer scar assessment scale in all the sub categories from day of discharge till day 30th of follow up None of the cases complaint of any surgical site infections or scar related complications. Conclusion: Electrocautery can be considered as effective and safe in making large skin incision. It is associated with less incision time, faster healing, low post-operative pain and good scar characteristics.

Outpatient surgery benchmarks and practice variation patterns: Case controlled study.

Despite numerous potential benefits of outpatient surgery, there is currently a lack of national benchmarking data available for hospitals and surgeons to compare their own outcomes as they transition toward outpatient surgery. Patients who underwent 14 common general surgery operations from 2016-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Operations were selected based on frequency and the ability to be performed both in- and outpatient. Postoperative complications and readmissions were compared between patients who underwent inpatient vs outpatient surgery. After adjusting for patient comorbidities, multivariable models assessed the effect of patient characteristics on the odds of experiencing postoperative complications. A separate multiinstitutional study of 21 affiliated hospitals assessed practice variation. In 13 of the 14 studied procedures, complications were lower for patients who were selected for outpatient surgery (all P<0.01); minimally invasive (MIS) adrenalectomy showed no difference (P=0.61). Multivariable analysis confirmed these findings; the odds of experiencing any adverse events were lower following outpatient surgery in all operations but MIS adrenalectomy (OR 0.97; 95% CI 0.47-2.02). Analysis of institutional practices demonstrated variation in the rate of outpatient surgery in certain breast, endocrine, and hernia repair operations. Institutional practice patterns may explain the national variation in the rate of outpatient surgery. While the present data does not support the adoption of outpatient surgery to less optimal candidates, addressing unexplained practice variations could result in improved utilization of outpatient surgery.

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines.

Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma. A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020. One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p <0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001). Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.

Resident dictation of operative notes: a reimbursement comparison and mixed-methods analysis

PurposeSurgical documentation is crucial to ensure quality patient care and accurate coding and billing. Operative dictation also serves as a valuable educational opportunity for surgical trainees. However, resident dictations may not fully capture procedural details and complexities, resulting in missed revenue opportunities. On July 1, 2021, our university-based surgery department implemented a policy requiring attendings to dictate all operative reports. The purpose of this mixed-method study was to investigate the financial impact of this policy and explore differences in resident and attending dictations.MethodsCore general surgery operations performed by the Department of Surgery between July 1, 2020 and June 30, 2022 were identified from billing data. The surgeon, current procedural terminology (CPT) and modifier codes, and relative value units (RVUs) for each case were acquired. Surgeons not present for the entire study period or cases requiring multiple surgeons were excluded. Descriptive statistics and Kolmogorov–Smirnov (KS) non-parametric tests compared pre- and post-policy RVU distributions on overall charges and 18 key general surgery operations. Targeted thematic analysis was performed on operative reports pre- and post-policy to explore resident and attending differences.ResultsA total of 42 attendings performed 16,233 cases, billing 28,560 CPT codes (50.3% pre- vs. 49.7% post-policy). There was a small but statistically significant increase in RVU distribution post-policy, mean 20.2 pre- vs. 20.3 RVUs post-, $4372 pre- vs. $4418 per case post-, KS = 0.02 (p = 0.009). Specifically, higher RVU distributions were seen among attending-dictated cases for melanoma (p = 0.009), minimally invasive ventral hernia repair (VHR, p = 0.008), parathyroidectomy (p < 0.001), anorectal incision and drainage (p = 0.003) and anorectal exam under anesthesia (p = 0.029). Higher RVU distributions were noted among resident-dictated, attending-edited cases for partial colectomy (p = 0.043), and open VHR (p = 0.004). No differences were noted among the remaining operations (p > 0.05). Three major themes were noted from focused sampling of 112 operative reports: billable items, clinical/surgical reasoning, and technical details. Differences in billable items and clinical and surgical reasoning were the most influential on modifying clinical implications of operative notes. Themes and differences were consistent regardless of surgeon or specialty.ConclusionAdopting an attending-only operative dictation policy yielded a small increase in billable RVUs, predominantly from select operations. Gaps in coding-directed language and depth of clinical reasoning were noted in resident dictations. These findings reveal an educational opportunity that concomitantly optimizes patient care, resident education, and procedural revenue.

Delayed return of bowel function after general surgery in South Australia

IntroductionReference ranges for determining pathological versus normal postoperative return of bowel function are not well characterised for general surgery patients. This study aimed to characterise time to first postoperative passage of stool after general surgery; determine associations between clinical factors and delayed time to first postoperative stool; and evaluate the association between delay to first postoperative stool and prolonged length of hospital stay. MethodsThis study included consecutive admissions at two tertiary hospitals across a two-year period whom underwent a range of general surgery operations. Multivariable logistic regression analyses were conducted to determine associations between the explanatory variables and delayed first postoperative stool, and between delayed first postoperative stool and length of hospital stay. The previously specified explanatory variables were used, with the addition of the dichotomised ≥4-day delay to first postoperative stool. Prolonged length of hospital stay was considered ≥7 days. Results2,212 general surgery patients were included. Median time to first postoperative stool was 2.28 (IQR 1.06–3.96). Median length of stay was 7.19 (IQR 4.50–12.01). Several operative characteristics and medication exposures were associated with delayed first postoperative stool. There was a statistically significant association between delayed first postoperative stool (≥4 days) and prolonged length of stay (≥7 days) (OR 4.34, 95 %CI 3.27 to 5.77, p < 0.001). ConclusionsThis study characterised expected reference ranges for time to return of bowel function across various general surgery operations and determined associations with clinical factors that may improve efficiency and identification of pathology within the postoperative course.

Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial

BackgroundInguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods. MethodsIn This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date. ResultsAfter 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery. ConclusionIt seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.