Operating Room Time Research Articles

The Incidence and Associated Factors of Patient Cancellation Scheduled for Elective Surgery From February to May at Debremarkos Comprehensive Spetialized Hospital, Debremarkos, Northwest Ethiopia, 2022 Gc. A Cross Sectional Study

Background: High rates of cancellation of surgical procedures are common in hospital settings, which may subsequently lead to economic loss to hospitals besides the burden given to patients, their families, and medical teams. It is well recognized that cancellation of patients from elective theatre operating lists increases cost, decreases efficiency, duplicates workload, and wastes operating room time. Cancellation of elective surgical procedures also causes significant emotional trauma to the patients as well as their families and the community in general, and its impact on hospital resources is great due to prolonged hospitalization and the high cost of health care [1]. This study aimed to assess the incidence and causes of patient cancellation scheduled for elective surgery in Debre Markos Comprehensive Specialized Hospital., Debremarkos, Northwest Ethiopia, 2022 GC. Methods and Materials: A prospective cross-sectional study was conducted on the cancellation of scheduled surgery at Debremarkos Comprehensive Specialized Hospital with a total of 282 sample size from February-01-May-13 consecutive months of 2022 G C. The data was collected from the operating room daily surgical schedule, preoperative anesthesia record sheet, primary physicians, and the anesthetist responsible for the preoperative assessment and conducting the case and by communicating patients if required. Analysis will be done by using SPSS (Version 20). Descriptive as well as analytic statistics are used for variables and data will be presented by tables, graphs, charts, and texts. Result: A total of 1055 patients were scheduled for elective Surgery in Debremarkos Comprehensive Specialized Hospital. During the study period 282(26.7%) of the patients had their surgery cancelled for various reasons in Debremarkos Comprehensive Specialized Hospital. The two most frequent reasons for cancellation were lack of bed (50.0%) and unfit for anesthesia (15.2%) in DMCSH. Conclusion and Recommendation: In conclusion, the cancellation rate of scheduled surgeries is high in general adult surgery at Debremarkos Comprehensive Specialized Hospital. The majority of causes are foreseeable and avoidable, and many are related to the hospital itself. We recommend that a facility for hospital preadmission be created.

Perspective: Efficacy and outcomes for different lumbar interspinous devices (ISD) vs. open surgery to treat lumbar spinal stenosis (LSS).

Interspinous devices (ISD) constitute a minimally invasive (MI) alternative to open surgery (i.e., laminectomy/decompression with/without fusion (i.e., posterior lumbar interbody fusion (PLIF)/posterolateral instrumented fusion (PLF)) for treating lumbar spinal stenosis (LSS). Biomechanically, static and/or dynamic ISD "offload" pressure on the disc space, increase intervertebral foraminal/disc space heights, reverse/preserve lordosis, limit range of motion (ROM)/stabilize the surgical level, and reduce adjacent segment disease (ASD). Other benefits reported in the literature included; reduced operative time (OR Time), length of hospital stay (LOS), estimated blood loss (EBL), and improved outcomes (i.e., ODI (Oswestry Disability Index), VAS (Visual Analog Scale), and/or SF-36 (Short-Form 36)). Various studies documented the relative efficacy and outcomes of original (i.e., Wallis), current (i.e., X-STOP, Wallis, DIAM, Aperius PercLID), and new generation (i.e., Coflex, Superion Helifix, In-Space) ISD used to treat LSS vs. open surgery. Although ISD overall resulted in comparable or improved outcomes vs. open surgery, the newer generation ISD provided the greatest reductions in critical cost-saving parameters (i.e., OR time, LOS, and lower reoperation rates of 3.7% for Coflex vs. 11.1% for original/current ISD) vs. original/current ISD and open surgery. Further, the 5-year postoperative study showed the average cost of new generation Coflex ISD/decompressions was $15,182, or $11,681 lower than the average $26,863 amount for PLF. Patients undergoing new generation ISD for LSS exhibited comparable or better outcomes, but greater reductions in OR times, EBL, LOS, ROM, and ASD vs. those receiving original/current ISD or undergoing open surgery.

Predictive modelling of total operating room time for Laparoscopic Cholecystectomy using pre-operatively known indicators to guide accurate surgical scheduling in a critical access hospital

The financial margin of rural and critical access hospitals highly depends on their surgical volume. An efficient operating room is necessary to maximise profit and minimise financial loss. OR utilisation is a crucial OR efficiency metric requiring accurate case duration estimates. The patient's age, ASA, BMI, Mallampati score, previous surgery, the planned surgery, the surgeon, the assistant's level of experience and the severity of the patient's disease are also associated with operative duration. Although complex machine-learning models are accurate in operative prediction, they are not always available in resource-limited hospitals. Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed and is one of the few procedures performed at critical access and rural hospitals. The accurate estimation of the operative duration of LC is essential for efficient OR utilisation. We hypothesise that a multivariate linear regression prediction model can be constructed from a set of pre-operatively known, easily collected variables to maximise OR utilisation and improve operative scheduling accuracy for LC. We further hypothesise that this model can be implemented in resource-limited environments, such as critical access hospitals.

Operating room variables: Endoscopic vs. vaginal surgery in postmenopausal women with apical prolapse. An analysis of retrospective data

Objective:Pelvic organ prolapse is a common condition with an increasing prevalence among elderly women. Currently, an efficient surgery to treat such a condition requires both cost-efficiency and time efficiency, since operating rooms also serve as the financial center of modern hospitals. This study is aimed at comparing different approaches to treating an apical prolapse based on perioperative variables, including operating room times and their efficiency. Materials and MethodsWe reviewed and compared the perioperative data of postmenopausal women over 60 who had undergone POP surgery for an apical prolapse via laparoscopic approach between 2012 and 2022 with women who underwent surgery via vaginal approach between 2018 and 2022. The groups were divided into subdivisions based on concomitant hysterectomy. The operating room time, perioperative complications, blood loss, and the time of hospital stay were compared under different groups. Results:A total of 199 patients were included in this study, out of which 66 underwent laparoscopic surgery and 133 underwent vaginal surgery for apical pelvic organ prolapse (POP). The vaginal approach showed significantly shorter operating room times when it came to the duration of anesthesia induction, case preparation, and the surgery. The blood loss did not significantly differ between the groups. The length of hospital stay was significantly longer in the groups with a laparoscopic approach. Conclusion:The advantage of traditional vaginal surgery is the significant time efficiency with better perioperative variables compared to the laparoscopic approach.

Current trends and outcomes for unilateral groin hernia repairs in the United States using the Abdominal Core Health Quality Collaborative database: A multicenter propensity score matching analysis of 30-day and 1-year outcomes

BackgroundDifferent unilateral groin hernia repair approaches have been developed in the last 2 decades. The most commonly done approaches are open inguinal hernia repair by the Lichenstein technique, laparoscopic approach by either total extraperitoneal or transabdominal preperitoneal, and robotic transabdominal preperitoneal approach. Hence, this study aimed to compare early and late postoperative outcomes in patients who underwent unilateral robotic transabdominal preperitoneal, laparoscopic transabdominal preperitoneal, and laparoscopic total extraperitoneal, and open groin hernia repair using a United States national hernia database, the Abdominal Core Health Quality Collaborative Database. MethodsProspectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent elective unilateral groin hernia repair from 2015 to 2022, with a 1:1 propensity score match analysis conducted for balanced groups. The univariate analysis compared the groups across the preoperative, intraoperative, and postoperative timeframes. ResultsThe Abdominal Core Health Quality Collaborative database identified 14,320 patients who underwent elective unilateral groin hernia repair and had documented 30 days of follow-up. Propensity score matching stratified 1,598 patients to each group (total of 6,392). The median age was 64 years (interquartile range 53–74) for open groin hernia repair, whereas 60 (interquartile range 47–69) for laparoscopic transabdominal preperitoneal, 62 (interquartile range 48–70) for laparoscopic total extraperitoneal, and 60 (interquartile range 47–70) for robotic transabdominal preperitoneal were noted. Open groin hernia repair had more American Society of Anesthesiologists score 4 (52, 3%) patients (P < .001). A painful bulge was the most common indication (>85%). Operating room time >2 hours was more significant in the robotic transabdominal preperitoneal group (123, 8%; P < .001). Seroma rate was higher in the laparoscopic transabdominal preperitoneal (134, 8%; P < .001). A 1-year analysis had 1,103 patients. Hematoma, surgical site infection, readmission, reoperation, and hernia recurrence at 30 days or 1 year did not differ, with an overall recurrence rate of 6% (n = 67) at 1 year (P = .33). In patients with body mass index ≥30 kg/m2, the robotic approach had lower rates of surgical site occurrence (n = 12, 4%; P = .002) and seroma (n = 5, 2%; P < .001) compared with the other groups. When evaluating recurrence 1 year after surgery, the robotic transabdominal preperitoneal group had 10% versus 18% open groin hernia repair, 11% laparoscopic transabdominal preperitoneal, and 18% laparoscopic total extraperitoneal, but it was not statistically significant (P = .53). ConclusionThere was no difference in readmission, reoperation, and surgical site infection among the surgical techniques at 30 days. However, laparoscopic transabdominal preperitoneal was associated with more seromas. Hernia recurrence at 1 year was similar across groups; the robotic approach had the lowest recurrence rate among all 3 repairs but did not reach statistical significance. The robotic approach performed better in patients with a body mass index of 30 kg/m2 for surgical site occurrence and seroma than in other surgical techniques.

Prophylactic Posterior Targeted Muscle Reinnervation (TMR) Approach in Below Knee (BKA) Amputation Settings

Background/Objective: Targeted muscle reinnervation (TMR) is a nerve reconstruction technique focused on improving phantom limb pain (PLP), residual limb pain (RLP), prosthesis function, and limiting neuroma formation. In below-knee-amputations (BKA), TMR performed "through-the-wound" is heavily documented. Alternatively, the "posterior approach" was developed to help increase visibility of peripheral nerves from the posterior fossa. This study focuses on the surgical efficiency and patient outcomes of the posterior approach compared to the through-the-wound approach. We hypothesize the posterior approach will be comparable toor improve time-to-prosthesis fitting, OR time, and pain scores.&#x0D; Methods: 157 patients underwent TMR at two hospitals in Indianapolis, IN, and were identified using CPT 64890. 39 patients underwent posterior approach TMR post-BKA. Data on demographics, follow-up/rehabilitation visits, post-operative complications, prosthesis fitting, and total OR time were collected. Additionally, 32 patients received TMR "through-the-wound", and total OR time, post-operative complications, and time-to-prosthesis fitting were tracked. Patient-reported outcome (PRO) surveys are being sent to patients pending IRB approval.&#x0D; Results: Of the 39 who received the posterior approach between 1/10/2020 and 4/6/2023, 25 received TMR in the right leg and 14 in the left. Following BKA, average time to TMR was 144 days. However, 18 patients received TMR directly after undergoing BKA (46.2%). Average OR time for acute and delayed posterior TMR patients was 208.06 minutes and 199.47 minutes, respectively. 10 patients reported post-operative complications (25.6%): dehiscence (12.8%) or infection (7.7%). 23 patients received prosthesis fitting on average 3 months post-op. Average OR time and time-to-prosthesis fitting for "through-the-wound" TMR surgeries were 192.84minutes and 5.81 months, respectively.&#x0D; Potential Impact: Posterior approach TMR had no significant impact on OR time, but time-to-prosthesis fitting significantly decreased. Once PRO surveys return, average long-term PLP and RLP can be determined. Preliminarily, posterior approach TMR improves aspects of patient outcomes while not compromising surgical efficiency.

Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Risk predictors of race disparity in patients undergoing coronary artery bypass grafting: a propensity-matched analysis.

The aim of this study was to compare long-term prognosis after isolated coronary artery bypass grafting between white and black patients and to investigate risk factors for poorer outcomes among the latest. All consecutive 4766 black and white patients undergoing isolated coronary artery bypass grafting between May 2005 and June 2021 at our institution were included. Primary outcomes were long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events in black versus white patients. A propensity-matched analysis was used 2 compare groups. After matching, 459 patients were included in each black and white groups while groups were correctly balanced. The mean age was 70.4 vs 70.6 years old (P = 0.7) in black and white groups, respectively. Intraoperatively, mean operating room time and blood product transfusion, were higher in the black group while incidence of extubation in the operating room was higher in the white one. Postoperatively, hospital length of stay was higher in the black cohort. Thirty-day all-cause mortality was not different among groups. The median follow-up time was 4 years. Primary outcome of all-cause death was higher in the black versus the white, respectively. Major adverse cardiovascular and cerebrovascular events incidence was twice higher in the black compared to the white cohort (7.6% vs 3.7%, P = 0.013). Risk predictors for all-cause death and major adverse cardiovascular and cerebrovascular events in blacks were creatinine level, chronic obstructive pulmonary disease, ejection fraction <50% and preoperative atrial fibrillation. Racial disparities persist in a high-volume centre. Despite no preoperative difference, black minority has a higher incidence of major adverse cardiovascular and cerebrovascular events.

Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective.

When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective. The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively. Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020). Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.

Advanced Multi-Layer Watertight Closure versus Conventional Closure in Total Hip and Knee Replacement Surgery.

In total joint replacement procedures, surgeons have increasingly adopted advanced multi-layer, watertight closure. The objective of the study was to compare the clinical and economic outcomes for advanced multi-layer, watertight closure patients to those with conventional closure with sutures and skin staples. Patients aged ≥18 years were included in the study if they underwent total joint arthroplasty of the hip or knee as an elective, primary, inpatient procedure between January 2014 and March 2019. Cohorts having advanced multi-layer, watertight closure or conventional closure were compared using multivariable regression analysis of surgical site infections, length of stay, operating room time, procedure time, discharge status, readmissions, reoperations, and hospital emergency department visits. A total of 1828 patients received at least one total hip or knee replacement, of which 434 (23.7%) had advanced multi-layer, watertight closure and 1394 (76.3%) had conventional closure. Unadjusted time to readmission, when occurring, was considerably longer following advanced multi-layer, watertight closure (89.9 vs 51.1 days, p < 0.0001), and a lower proportion of the advanced multi-layer, watertight closure cohort required reoperation within 90 days (0.0% vs 2.6%, p < 0.0001). Adjusted mean hospital length of stay was approximately half of a day shorter for advanced multi-layer, watertight closure patients (1.10 vs 1.65 days; p < 0.001), and they were also more likely to be discharged to home (Odds Ratio: 4.61; p = 0.002). Among patients undergoing total hip and knee arthroplasty in a highly optimized real-world clinical practice, advanced multi-layer, watertight closure was associated with significantly shorter inpatient length of stay and increased likelihood of being discharged to home compared with conventional closure. These findings suggest that advanced multi-layer, watertight closure is a valuable component of an optimal workflow for total hip or knee replacement, and may be especially valuable for high-risk patients.

Pre-aspiration outpatient ultrasound can accurately predict dry taps in prosthetic hips suspected of infection; a prospective study.

Aspiration represents the most potent method for exploring the potential occurrence of Periprosthetic Joint Infection (PJI). However, dry taps are common. While aspiration under ultrasound (US) guidance in the radiology department has become increasingly popular, hip aspiration is still routinely conducted in the operating room (OR) under x-ray guidance in numerous medical centers. When conducted within the confines of the OR, a dry tap aspiration not only subjects the patient to an unnecessary invasive procedure but also constitutes a substantial strain on OR time and resources. Our objective was to assess whether an outpatient US conducted before aspiration could reliably predict the likelihood of encountering a dry hip aspiration. In a prospective study, we enrolled 50 hips who were suspected of PJI and slated for revision total hip arthroplasty and required hip aspiration. Before the aspiration procedure, we conducted an outpatient hip ultrasound (US) to assess the presence of fluid collection. Subsequently, all patients underwent aspiration under fluoroscopy in the OR, irrespective of the ultrasound findings We then assessed the level of agreement between the ultrasound results and the outcomes of hip aspiration. The US exhibited a sensitivity of 95.7% (95% CI 69.8-91.8), a specificity of 74.1% (95% CI 52.8-91.8), a positive predictive value of 75.9% (95% CI 50.9-91.3), and a negative predictive value of 95.2% (95% CI 71.3-99.8) in predicting the success of aspiration. Pre-aspiration outpatient US demonstrates a high degree of accuracy in predicting dry taps in these patients. We recommend its incorporation into the hip aspiration procedure in medical centers where aspiration is performed in the operating room. In the broader context, these findings reinforce the preference for US-guided aspiration within the radiology department over x-ray-guided aspiration in the operating room since about ¼ of the positive USs for hip collection will lead to a dry tap if the aspiration is performed in the OR under fluoroscopy guidance.

Techniques to Reduce the Rate of Infection in Surgeries for Cerebrospinal Fluid Shunting in Adults

ObjectiveCerebrospinal fluid (CSF) shunt placement is associated with high rates of infection. Multiple standardized protocols, particularly in pediatric populations, have been proposed to mitigate this infection rate. We sought to determine the effectiveness of a standardized shunt infection protocol in a large adult population. MethodsA retrospective cohort study of adults presenting for primary CSF shunt placement from 2012-2022. The primary outcome of interest was shunt infection. The primary exposure of interest was implementation of the shunt protocol (began October 2015). Secondary exposures of interest included use and type of perioperative antibiotics and total OR time. ResultsIn total, 820 patients were included, 140 before protocol implementation and 680 after protocol implementation. The overall number of infections over the study period was 15 (1.8% infection rate), with 8 infections pre-protocol (5.7%) and 7 infections during the protocol period (1.0%). The infection protocol was associated with a decreased infection rate (OR 0.18, 95% CI 0.05-0.58, p=0.002). Total operating room time (OR 1.38 per 30-minute increase, 95% CI 1.05-1.81, p=0.021) was associated with increased infection rate. Patients who received antibiotics with primarily gram-positive coverage (cefazolin or equivalent) did not have significantly different odds of shunt infection as patients who received broad-spectrum coverage (OR 2.10, 95% CI 0.56-7.88, p=0.274). ConclusionsThe implementation of an evidence-based perioperative shunt infection protocol is an effective method to decrease shunt infections. Broad-spectrum perioperative antibiotics may not have greater efficacy than gram-positive only coverage, but more research is required.

The Effect of Obesity on Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fractures.

Obesity is a well-recognized global epidemic that can lead to longer operative times as well as a greater technical demand. Despite this, the available literature evaluating the impact of obesity on hip hemiarthroplasty (HA) and total hip arthroplasty (THA) when treating fractures about the femoral neck is scarce. Between 2015 and 2018, we retrospectively reviewed all patients that had a HA or THA performed as treatment for an isolated fracture of the femoral neck. Patients were classified as obese and nonobese depending on current body mass index (BMI) when the index procedure was performed. Preoperative and postoperative variable were obtained from the electronic medical record. A total of 157 patients underwent hip HA or THA for an isolated fracture of the femoral neck. In those patients undergoing HA, obesity was associated with an increase in operative times (P = 0.021) and was associated with a nonsignificant increase in total operating room time (P = 0.088) and duration of anesthesia (P = 0.14). In those patients undergoing THA, obesity was associated with longer operative times (P = 0.043), total operating room time (P = 0.032), and duration of anesthesia (P = 0.045). There were no significant differences in complication rates postoperatively between obese and non-obese patients undergoing either procedure. The treatment of isolated fractures of the femoral neck with HA or THA leads to an increase in operative time without an increase in postoperative complications in obese patients.

Patient Perception of Robotic Total Hip Arthroplasty: A Qualitative Study

Introduction: Total hip arthroplasty (THA) is one of the most commonly performed orthopedic surgeries, at a prevalence of around 0.8% in the United States. Robotic-assisted technology has the goal of optimizing outcomes by improving acetabular cup positioning, center of hip rotation, and more. Patient perceptions regarding this procedure are not clearly delineated in the literature; therefore, the purpose of this study was to assess why patients choose to undergo robotic-assisted THA and whether they would recommend a similar procedure. Methods: All patients who underwent robotic-assisted THA between May 31, 2017 and December 13, 2018 were given a 12-question survey to complete. The final cohort consisted of 51 patients composed of 32 men and 19 women with a mean age of 67 years (range, 40 to 84 years). All de-identified surveys were evaluated for assessment. Results: Ninety-two percent would recommend robotic-assisted THA as opposed to conventional THA, with 70% stating the main influencer in their decision was physician input. 68 percent believed they would achieve better outcomes with robotic THA as opposed to their conventional counterparts. Seventy-two percent thought their components would be placed in a more optimal position using robotics. 49% believed they would have less pain with robotic-assisted THA. However, most patients stated they believe they would have no difference in length-of-stay or infection risk compared to manual THA. 53 percent of patients stated there would be similar operating room time between robotic and manual THA. Discussion: The majority of our cohort believed there were benefits to undergoing robotic-assisted THA. Physician input was the major contributing factor. Larger prospective studies in the future with less limitations should evaluate how attitudes and beliefs may influence patient-reported satisfaction and outcomes post-operatively.

Clinical Characteristics and Outcomes of Elective Gynecologic Cases Using Modified Medically Necessary, Time Sensitive (MeNTS) Scoring System in the Prioritization of Surgery at the Philippine General Hospital during the COVID-19 Pandemic.

The use of a scoring system that integrates various factors helps in decision-making and triage for Medically Necessary, Time Sensitive (MeNTS) surgical procedures during the COVID-19 pandemic. This study aimed to determine the clinical characteristics and outcomes of cases who were screened and underwent elective gynecologic surgery at a tertiary hospital using the MeNTS tool for prioritization. A cross-sectional study was carried out using data collected through medical chart review of all gynecologic cases screened in a 6-month period, from June 18, 2020 to December 18, 2020. A total of 155 gynecologic cases were screened, with 134 (86.4%) MeNTS cases and 21 (13.5%) non-MeNTS cases. The median length of stay (5 days), the median operating room time (3 hours and 30 minutes), and median estimated blood loss (400 ml) were within the acceptable expected outcome as with the scoring system, albeit with some cases (53%) requiring blood transfusion attributed to low baseline hemoglobin levels. There were no cases with post-operative COVID-19 transmission, needing ICU care and intubation, nor mortalities reported. The MeNTS scoring system allowed efficient handling of the backlog of elective gynecologic cases with minimal morbidity and absence of mortality. The study supports the utility of this scoring system in addressing the need of the healthcare system not just to optimally utilize and fairly allocate hospital resources but also to ensure the safety of the patient with the best health service delivery during the pandemic.

Thyroidectomy Outcomes in Obese Patients

IntroductionObese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery. MethodsA retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed. ResultsThere were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy. ConclusionsExcellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery And Orthopedic Injuries

The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P=0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P=0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25years is 100%. In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Virtual surgical planning for mandibular reconstruction in an abbreviated admission pathway

ObjectivesVirtual Surgical Planning (VSP) creates individualized surgical plans for free flap reconstruction of mandibular defects. Prior studies indicate that VSP can offer cost benefits due to reduced operative time and length of stay (LOS). We assessed the impact of VSP in the context of a validated postoperative abbreviated LOS clinical pathway. MethodsThis study assessed patients undergoing VSP vs conventional fibular free flap reconstruction for mandibular defects (12/2015–10/2020) and their operative time, ischemia time, and LOS were evaluated. ResultsForty-four patients underwent VSP reconstruction, while 52 patients underwent conventional reconstruction for mandibular defects. VSP was associated with significantly lower total operative time (6 h and 57 mins vs 7 h and 54 mins, p = 0.011), but not length of stay or ischemia time. Total OR time was significantly increased with increasing number of segments needed in both the VSP group (p = 0.002) and the conventional group (p = 0.015). ConclusionShorter operative times and LOS have been attributed to the use of VSP in free tissue transfers. It is argued that these reductions offset the added cost of VSP. Our study indicates that there is no cost benefit for VSP utilization due to a significantly reduced operative time with no impact on length of admission in an abbreviated admission clinical pathway following free tissue transfer.

Radiographic characteristics-based classification system for percutaneous endoscopic lumbar discectomy surgical approach selection in patients with L5-S1 disc herniation: a hierarchical clustering analysis.

No classification system exists for aiding the selection of surgical approaches in L5-S1 disc herniation when undergoing percutaneous endoscopic lumbar discectomy (PELD). We aimed to identify radiographic subtypes to aid the selection of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) in patients with L5-S1 disc herniation via unsupervised hierarchical clustering analysis. In this retrospective case-control study, we gathered 296 anteroposterior and lateral lumbar spine radiographs (dataset 1) from Tianjin Hospital between January 2016 and October 2021 for clustering analyses. Additionally, we analyzed 111 patients who underwent PEID or PETD for L5-S1 disc herniation at Tianjin Hospital from January 2016 to August 2022. We included patients with radicular leg pain or back pain associated with intra-canal disc herniation who failed in conservative treatments over 6 weeks. First, pair-wise Spearman correlation coefficients were calculated among plain radiographic metrics in dataset 1 to reveal the association among these radiographic metrics. Second, hierarchical clustering analysis was conducted to unsupervised cluster the plain films into several subtypes. Last, for each radiographic subtype, the intraoperative blood loss (IBL), operation time (OT), total operating room time (TORT) along with visual analogue scale (VAS) and Oswestry Disability Index (ODI) were compared between patients underwent PETD or PEID with age as covariates. This study yielded 3 main findings: (I) iliac height (IH) was negatively correlated with intervertebral foramen width (IFW), intervertebral foramen height (IFH), and intertransverse height (ITH) (R=-0.50, -0.42, and -0.46, all P<0.001), ITH was positively correlated with IFW and IFH (R=0.40 and 0.53, all P<0.001); (II) 2 lumbosacral radiographic subtypes were identified via hierarchical clustering analysis; (III) relative to subtype 1, the patients identified as subtype 2 exhibited lesser IBL, shorter OT, and shorter TORT following PETD (t=2.92, P=0.006; t=2.65, P=0.012; t=3.17, P=0.003). The morphology pattern of the lumbosacral region affect the ease of different PELD procedures when performing percutaneous discectomy at the segment of L5-S1. Without considering the type of disc herniation, this classification system might aid spine surgeons in the selection of an appropriate surgical approach.

A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017–2020

BackgroundRobotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied.MethodsThe PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2).ResultsRAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging.ConclusionsA comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.