Primary Surgeon Research Articles

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH. The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before. Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Surgical confidence when operating among residents in surgery – a cross-sectional study (SCAR study)

BackgroundSelf-confidence, is one of the critical variables influencing surgical resident’s abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it.MethodsCross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05.ResultsResponse rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program.ConclusionThe study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it’s important to recognize that confidence doesn’t necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure.

Assessing Resident Cataract Surgical Outcomes Using Electronic Health Record Data.

To demonstrate that electronic health record (EHR) data can be used in an automated approach to evaluate cataract surgery outcomes. Retrospective analysis. Resident and faculty surgeons. Electronic health record data were collected from cataract surgeries performed at the Johns Hopkins Wilmer Eye Institute, and cases were categorized into resident or attending as primary surgeon. Preoperative and postoperative visual acuity (VA) and unplanned return to operating room were extracted from the EHR. Postoperative VA and reoperation rate within 90 days. This study analyzed 14 537 cataract surgery cases over 32 months. Data were extracted from the EHR using an automated approach to assess surgical outcomes for resident and attending surgeons. Of 337 resident surgeries with both preoperative and postoperative VA data, 248 cases (74%) had better postoperative VA, and 170 cases (51%) had more than 2 lines improvement. There was no statistical difference in the proportion of cases with better postoperative VA or more than 2 lines improvement between resident and attending cases. Attending surgeons had a statistically greater proportion of cases with postoperative VA better than 20/40, but this finding has to be considered in the context that, on average, resident cases started out with poorer baseline VA.A multivariable regression model of VA outcomes vs. resident/attending status that controlled for preoperative VA, patient age, American Society of Anesthesiologists (ASA) score, and estimated income found that resident status, preoperative VA, patient age, ASA score, and estimated income were all significant predictors of VA. The rate of unplanned return to the operating room within 90 days of cataract surgery was not statistically different between resident (1.8%) and attending (1.2%) surgeons. This study demonstrates that EHR data can be used to evaluate and monitor surgical outcomes in an ongoing way. Analysis of EHR-extracted cataract outcome data showed that preoperative VA, ASA classification, and attending/resident status were important in predicting postoperative VA outcomes. These findings suggest that the utilization of EHR data could enable continuous assessment of surgical outcomes and inform interventions to improve resident training. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Intentional enterotomies: validation of a novel robotic surgery training exercise.

While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick's validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.

(356) Microsurgical Training in a High-volume Academic Infertility Practice. What we Learn from the Residents

Abstract Introduction Surgical education has been traditionally rooted in the apprenticeship model, where the experts teach the surgeons-in-training during real-time surgeries. With the advent of robotics, the emphasis on simulation and virtual reality training is upon us. Objective The goal of this study is to examine lessons learned from the first few years of our institution’s microsurgical training. Methods A structured resident male infertility microsurgical training program was devised and multiple attempts at implementing it were made. When resident lack of interest/ time availability as well as COVID pandemic factored in, adjustments were made. And the devised assessment was applied to real-time surgeries. A structured assessment of the trainee’s skills was used by the faculty surgeon at initiation of the training, and throughout. All aspects of the assessment were evaluated on the scale of 1-5, with 1 being the lowest and 5 the highest. (Table 1) According to the individual improvement, the difficulty of the skills and steps of the procedure were advanced accordingly. This evaluation was not communicated with the trainees in order to avoid their undue stress/ intimidation. Results A total of 78 microscopic vasectomy reversal surgeries were performed by one staff surgeon and four consecutive resident surgeons between January 2020 and May 2022. All residents were in their 2nd year of Urology training (PGY-2). On average, each of the trainees participated in 17 vasectomy reversals (13-21), with similar amount of surgical time spent (about 3-4 hrs/ case). At initiation of their training, each individual had similar basic and microscopic surgical skills, procedure knowledge, economy of motion and tissue/ instrument/ needle handling ability (scores of 2-3 out of 5). Two of the trainees displayed higher level of interest and better listening skills, which resulted in willingness to correct their errors and ultimately improve on their surgical techniques. The resident with initial poor skill set and poor interest/ listening skills did not progress to more advanced stages of training and was relegated to initial dissection/ exposure and placement of adventitial sutures. The resident with slightly better surgical skills but unwilling to make corrections to his technique, progressed to the next level of placing occasional luminal sutures. The remaining two residents displayed the most interest, involvement and receptiveness to the feedback. They both progressed to the final stages of the training, with one of them performing the entire operation as a primary surgeon, with the staff assisting. (Table 2). Conclusions While the structured residency microsurgical training program is of utmost importance, competing professional and personal interests of the resident-surgeons may affect its full execution. Careful observation of the trainees, their skills, ability to receive and process the feedback in combination with teaching faculty’s patience and flexibility are paramount to the safe and effective “real-life” training. When devising a surgical training program it is important to keep in mind that surgical residents prefer hands-on operating experiences. Disclosure No

The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion

BACKGROUND CONTEXTAlthough incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population. PURPOSETo identify patient barriers to PROM completion one year following lumbar spine fusion. STUDY DESIGN/SETTINGRetrospective single-institution cohort study. PATIENT SAMPLEA total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURESCompletion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively. METHODSA retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients’ zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders. RESULTSA total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers’ compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion. CONCLUSIONSSocial determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.

Factors influencing the decision-making process for breast surgery in women likely to face breast cancer: a cross-sectional study.

The authors conducted a study to investigate the factors influencing the choice of breast surgery. To be eligible for this study, participants had to be Lebanese women, with no age limit and willing to participate voluntarily. A questionnaire form was used to collect data related to patient demographics, health, surgery, and relevant factors. Data analysis was performed by statistical tests using IBM SPSS Statistics software (version 25) and Microsoft Excel spreadsheet (Microsoft 365). Significant factors (defined as P<0.05) were than used to determine the factors that influenced women's decision-making. Data from 380 participants were analyzed. The majority of participants were young (41.58% were between 19 and 30 years old), living in Lebanon (93.3%), and had a bachelor's degree or higher (83.95%). Almost half of the women (55.26%) are married and have children (48.95%). Among the participants, 97.89% had no personal history of BC, and 95.79% had not undergone any breast surgery. The majority of participants indicated that their primary care physician and surgeon influenced their decision on the type of surgery they take (56.32 and 61.58%, respectively). Only 18.16% of respondents said they had no preference for Mx over BCS. While the others listed their reasons and concerns for choosing Mx, including: concern about recurrence (40.26%), concern about residual cancer (31.05%). 17.89% of the participants justify the reason for choosing Mx rather than BCS, by the fact that they lack information on BCS. Most of the participants confirmed the importance of clarifying all information about BC and treatment options before being affected by a malignancy (71.84%) of which 92.28% preferred to participate in the next online lectures about this topic. The assumption of equal variance is assumed. Indeed, according to the Levene Test (F=1.354; P<0.05), there is a significant difference between the age categories of the group that prefers Mx (2.08) and the group that does not prefer Mx over BCS (1.77). Based on an independent samples t-test (t(380)=2.200; P<0.05). On the other hand, the preference of Mx over BCS is statistically dependent on the choice of contralateral prophylactic mastectomy. Indeed, according to the χ2-test, the relationship between the two variables is significant (χ2 (2)=8.345; P<0.05). The 'Phi' statistic measures the intensity of the relationship between the two variables in question (φ=0.148); therefore, the relationship between the preference of Mx rather than BCS and the asking of contralateral prophylactic Mx is strong and significant (P<0.05). However, there was no statistically significant dependence between the preference of Mx and the other factors studied (P>0.05). BC poses a problem for affected women, especially when they are asked to choose between a Mx or a BCS. Several complex factors affect and influence their decision and lead them to decide. Understanding these factors helps us to properly help these women choose. In this study, the authors demonstrated all the factors that can influence the choice of Lebanese women prospectively, and we stressed the need to explain all the modalities before being diagnosed.

Role Reversal Between Trainees and Surgeons: Improving Autonomy and Confidence in Surgical Residents

IntroductionThere are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons. MethodsThis is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years. ResultsThirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative “rescues” were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication. ConclusionsIntraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.

Assisting in Microsurgery: Operative and Technical Considerations

Microsurgery is technically challenging, typically requiring a primary surgeon and an assistant to complete several key operative steps. These may include manipulation of fine structures, such as nerves or vessels in preparation for anastomosis; stabilization of the structures; and needle driving. Even seemingly mundane tasks of suture cutting and knot tying require fine coordination between the primary surgeon and assistant in the microsurgical environment. Although prior literature discusses the implementation of microsurgical training centers at academic institutions and residency programs, there is a paucity of work describing the role of the assistant surgeon in a microsurgery operation. In this surgical technique article, the authors discuss the role of the assisting surgeon in microsurgery, with recommendations for trainees and attendings alike.

VALIDATION OF A VIRTUAL REALITY SIMULATOR FOR INTRAMEDULLARY FEMORAL NAIL APPLICATION DURING AN ORTHOPAEDIC SURGICAL COURSE

To investigate the utility of virtual reality (VR) simulators in improving surgical proficiency in Orthopaedic trainees for complex procedures and techniques.Fifteen specialty surgeons attending a London Orthopaedic training course were randomised to either the VR (n = 7) or control group (n = 8). All participants were provided a study pack comprising an application manual and instructional video for the Trochanteric Femoral Nail Advanced (TFNA) procedure. The VR group underwent additional training for TFNA using the DePuy Synthes (Johnson and Johnson) VR simulator. All surgeons were then observed applying the TFNA in a Sawbones model and assessed by a blinded senior consultant using three metrics: time to completion, 22-item procedure checklist and 5-point global assessment scale.Participant demographics for the VR and control groups were similar in context of age (mean [SD]: VR group, 31.0 [2.38] years; control group, 30.6 [2.39] years), gender (VR group, 5 [71%] men; control group, 8 [100%] men) and prior experience with TFNA (had applied TFNA as primary surgeon: VR group, 6 [86%]; control group, 7 [88%]). Although statistical significance was not reached, the VR group, on average, outperformed the control group on all three metrics. They completed the TFNA procedure faster (mean [SD]: 18.2 [2.16] minutes versus 19.78 [1.32] minutes; p&lt;0.189), performed a greater percentage of steps correctly (79% versus 66%; p&lt;0.189) and scored a higher percentage on the global assessment scale (75% versus 65%; p&lt;0.232).VR simulators offer a safe and accessible means for Orthopaedic trainees to prepare for and supplement their theatre-based experience. It is vital, therefore, to review and validate novel simulation-based systems and in turn facilitate their improvement. We intend to increase our sample size and expand this preliminary study through a second upcoming surgical course for Orthopaedic trainees in London.

MP58-06 EVALUATION OF A TOUCH-BASED IMAGE GUIDANCE SYSTEM FOR ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP58-06 EVALUATION OF A TOUCH-BASED IMAGE GUIDANCE SYSTEM FOR ROBOTIC PARTIAL NEPHRECTOMY Shaan Setia, Piper Canon, James Ferguson, Nicholas Kavoussi, Robert Webster, and Duke Herrell Shaan SetiaShaan Setia More articles by this author , Piper CanonPiper Canon More articles by this author , James FergusonJames Ferguson More articles by this author , Nicholas KavoussiNicholas Kavoussi More articles by this author , Robert WebsterRobert Webster More articles by this author , and Duke HerrellDuke Herrell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Image-guidance during robotic partial nephrectomy (rPN) employs a 3D model of renal anatomy to allow for sub-surface identification of structures. Most image guidance surgery (IGS) systems involve manual registration, which is inaccurate and requires a separate individual to align the model intraoperatively. We sought to evaluate an automated, touch-based 3D IGS system and its accuracy compared to expert surgeons. METHODS: We identified patients with renal masses with planned rPN. Preop CT scans were used to generate virtual patient-specific 3D anatomical kidney models. Our IGS system was deployed during 6 rPNs by two primary surgeons. Registration was achieved by aligning a touch-based point cloud of the kidney surface tracing (using the robotic tool tip) to the models. The primary surgeon used the tool tip to estimate the location of the renal artery, vein, tumor centroid and intersection of the mass with parenchyma. After registration, a secondary surgeon (blinded to preop imaging) used the tool tip to record the location of these structures with the IGS system. The ground-truth, intraoperative locations of the target structures were recorded after dissection was complete. Target registration errors (TRE) with and without IGS were compared. RESULTS: Computed registration was performed successfully across 6 patients (mean axial diameter 3.0 cm, mean nephrometry score 6.5, Figure 1). After surface tracing, registration on average took 100 seconds. Median overall TRE for the secondary surgeon using the IGS compared to the primary surgeon was 9.8 vs 8.6 mm, respectively (p=0.25). TRE of localization was less for the lesion intersection with kidney (3.7 vs 2.2 mm, p=0.43) compared to the renal artery (14.1 vs 18.7 mm, p=0.61) and vein (14.4 vs 9.6 mm, p=0.06) (Figure 2). CONCLUSIONS: We report an automated, touch-based IGS system for rPN. The system is as accurate as an expert surgeon in target structure identification, though accuracy of registration for rigid structures was better than that of hilar vessels. Further improvements are needed to accurately model tissue deformation especially for hilar anatomy. Source of Funding: NIH R01-EB023717Software interface support from Intuitive © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e797 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shaan Setia More articles by this author Piper Canon More articles by this author James Ferguson More articles by this author Nicholas Kavoussi More articles by this author Robert Webster More articles by this author Duke Herrell More articles by this author Expand All Advertisement PDF downloadLoading ...

179 Measuring Real Time Radiation Exposure to Spine-Focused Neurosurgeons

INTRODUCTION: C-arm fluoroscopy and O-arm navigation are vital tools in modern spine surgeries, but their repeated usage can endanger spine surgeons. While a surgeon’s chest and abdomen are protected by lead aprons, the eyes and extremities generally receive less protection. METHODS: This prospective cohort study includes 65 consecutive spine surgeries performed by a single spine-focused neurosurgeon over a 9-month period. Radiation exposure to the primary surgeon was measured through dosimeters worn over the lead apron, under the lead apron, on surgical loupes, and as a ring on the dominant hand. Differences were assessed with rigorous statistical testing and radiation exposure per surgical case was extrapolated. RESULTS: During the study, the measured radiation exposure over the apron, 176 mrem, was significantly greater than that under the apron, 8 mrem (p = .0020), demonstrating shielding’s protective effect. The surgeon’s dominant hand was exposed to 329 mrem while the eyes were exposed to 152.5 mrem of radiation. Compared to the surgeon’s protected abdominal area, the hands (p = .0002) and eyes (p=.0002) received significantly greater exposure. Calculated exposure per case was 2.8 mrem for the eyes and 5.1 mrem for the hands. It was determined that a spine-focused neurosurgeon operating 400 cases annually will incur a radiation exposure of 60,750 mrem to the hands and 33,900 mrem to the eyes over a 30-year career. CONCLUSIONS: Our study found that spine surgeons encounter significantly more radiation exposure to the eyes and the extremities compared to protected body regions. Lifetime exposure exceeds the annual limits set by the International Commission on Radiological Protection for the extremities (50,000 mrem/yr) and the eyes (15,000 mrem/yr), calling for increased awareness about the dangerous levels of radiation exposure that a spine surgeon incurs over one’s career.

Training Veterinary Ophthalmology Residents on Cataract Surgery (Part A: Diplomate's Survey).

The purpose of this study was to explore the teaching methods used to train residents in cataract surgery at academic and private practice institutions. A descriptive survey was distributed online to 186 active supervising diplomates of the American Board of Veterinary Ophthalmologists (ABVO) listserve. The survey included items about various educational resources and techniques available to ophthalmology residents when performing cataract surgery. Thirty-seven (19.9%) supervising diplomates completed the survey. Most supervising diplomates (29, 78.4%) required supervised practice in the wet lab. Fourteen supervising diplomates (37.8%) provided mandatory cataract surgery lectures. Nine diplomates (24.3%) required their residents to attend a formal phacoemulsification wet lab course. There was no difference in the number of diplomates who allowed their residents to perform cataract surgery as the primary surgeon during their second year compared to any other year. Thirty-three surveyed diplomates supported the idea of creating an assessment tool to improve surgical competency. This article describes the current trends in veterinary ophthalmology residency education and provides support for the creation of an assessment tool to improve surgical competency. The goal is to stimulate future research on how educators can effectively train veterinary ophthalmology residents to improve surgical proficiency.

Utilisation of private general practitioners to provide caesarean deliveries in five rural district public hospitals in South Africa: a mixed-methods study

ObjectiveResearching how public–private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general...

A Prospective Cohort Study of Radiation Exposure to a Spine Surgeon's Exposed Body Parts During Utilization of Intraoperative Radiation-based Imaging.

Prospective cohort study. C-arm fluoroscopy and O-arm navigation are vital tools in modern spine surgeries, but their repeated usage can endanger spine surgeons. Although a surgeon's chest and abdomen are protected by lead aprons, the eyes and extremities generally receive less protection. In this study, we compare differences in intraoperative radiation exposure across the protected and unprotected regions of a surgeon's body. Sixty-five consecutive spine surgeries were performed by a single spine-focused neurosurgeon over 9 months. Radiation exposure to the primary surgeon was measured through dosimeters worn over the lead apron, under the lead apron, on surgical loupes, and as a ring on the dominant hand. Differences were assessed with rigorous statistical testing and radiation exposure per surgical case was extrapolated. During the study, the measured radiation exposure over the apron, 176 mrem, was significantly greater than that under the apron, 8 mrem (P = 0.0020), demonstrating a shielding protective effect. The surgeon's dominant hand was exposed to 329 mrem whereas the eyes were exposed to 152.5 mrem of radiation. Compared with the surgeon's protected abdominal area, the hands (P = 0.0002) and eyes (P = 0.0002) received significantly greater exposure. Calculated exposure per case was 2.8 mrem for the eyes and 5.1 mrem for the hands. It was determined that a spine-focused neurosurgeon operating 400 cases annually will incur a radiation exposure of 60,750 mrem to the hands and 33,900 mrem to the eyes over a 30-year career. Our study found that spine surgeons encounter significantly more radiation exposure to the eyes and the extremities compared with protected body regions. Lifetime exposure exceeds the annual limits set by the International Commission on Radiologic Protection for the extremities (50,000 mrem/y) and the eyes (15,000 mrem/y), calling for increased awareness about the dangerous levels of radiation exposure that a spine surgeon incurs over one's career.

A Multicenter Study Investigating the Surgeon Experience with a Robotic-Assisted Exoscope as Part of the Neurosurgical Armamentarium

Improvement of visualization tools in neurosurgery such as the exoscope has raised the question of how this technology compares to the conventional microscope for surgeon ergonomics, discomfort, and patient outcomes. Exoscopes have the advantage of greater optical zoom, resolution, and illumination at a lower light intensity. Heads-up display for both the primary surgeon and other assistants permits neutral positioning of the surgeons while placing the camera in more angled positions. In a survey sample, this study assesses the surgeon experience utilizing 3D exoscope in general neurosurgery cases. Data weere recorded by 8 surgeons at 5 separate hospitals utilizing a mobile phone application survey. Surgeons recorded information about case type, intraoperative clinical outcomes such as blood loss and extent of resection, whether fluorescence visualization was used, as well as surgeon pain when compared to matched cases using conventional tools. A total of 155 neurosurgical cases were recorded in this multisite study, including 72% cranial cases and 28% spinal cases. Of the cranial cases, 76% were brain tumor resections (31% of which were brain metastases). Surgeons reported significantly less neck (P < 0.0001) and back (P < 0.0001) pain in cases when using the robotic exoscope compared with the conventional microscope or surgical loupes. Surgeons did not convert to a microscope in any case. The exoscope provides excellent delineation of tissue with high resolution. Surgeon pain was markedly reduced with the robotic exoscope when compared with conventional technology, which may reduce work-related injury and fatigue, potentially leading to better patient outcomes.

Minimally Invasive Glaucoma Surgery (MIGS) using a 3D Digital Surgical Ophthalmic Exoscope

Intraoperative positioning required for direct gonioscopy during minimally invasive glaucoma surgery (MIGS) can pose a challenge for the patient, the surgeon, and the surgical trainee. With traditional optical microscopy, the patient's head, the microscope, and the surgeon's oculars must all be adjusted to achieve an adequate view of the iridocorneal angle. Even then, the surgical view is often inferior for observing or assisting trainees. This video demonstrates several benefits of digital microscopy using the Beyeonics One™ Surgical Exoscope (Beyeonics Surgical, Israel) and an augmented reality (AR) 3D immersive headset. The digital exoscope can be triggered to auto tilt to facilitate direct gonioscopy. The degree to which the exoscope and the patient's head are adjusted may be less than what one traditionally requires with optical microscopy. Surgeon working distance should also be less affected. A digital recenter feature maintains a centered view without having to physically move the camera. The surgeon, who is wearing an immersive headset, does not have to move or adjust the oculars. The foot pedal or headset can be used for fine focus or zoom. The gonioscopic view is near identical to optical microscopy, but the digital technology and automation allow for improved ergonomics and enhanced visualization. A trainee can also don a headset for an identical view to the primary surgeon.

Surgical resident operative autonomy on nights and weekends: What happens to surgical education during off-hours?

Surgical resident operative autonomy is critical for trainee maturation to independence. Acute care surgery (ACS) cases commonly occur off-hours and tension between operating room availability and on-call staff can affect resident operative autonomy. We examined operative resident autonomy for general, vascular, and thoracic (GVT) surgery during nights and weekends. We hypothesized that residents would be afforded less operative autonomy during off - hours than weekdays. This retrospective cohort study uses the Veterans Affairs Surgical Quality Improvement Program database, we examined all GVT cases at Veterans Affairs teaching hospitals from 2004 to 2019. All cases are coded for the level of supervision at the time of surgery: AP, attending primary surgeon; AR, attending and resident operating together; and RP, resident primary (attending supervising but not scrubbed). Cases starting between 6 pm to 7 am Monday through Friday were considered nights, cases on Saturday/Sunday were considered weekends, and collectively considered "off-hours." Resident primary case rates were compared by start time and type. Over the 15-year study period, there were 666,421 GVT cases performed with 38,097 cases (6%) performed off-hours. During off-hours, 31,396 (83%) were ACS compared with 5% of daytime cases. Overall, off-hours cases have higher RP rate than daytime cases (6.8% vs. 5.8%, p < 0.001). Daytime ACS cases have higher rates of RP than nights/weekends (7.6% vs. 6.8%, p < 0.001). Conversely, daytime elective cases have lower RP than nights (5.7% vs. 7.9%, p < 0.001). During off-hours, there are more RP cases on nights compared with weekends (7.1% vs. 6.5%, p = 0.02). Overall, residents were afforded more operative autonomy during off-hours, with nights having greater RP than weekends. In contrast, ACS cases have more autonomy during weekdays. These data have potentially significant implications for ACS service staffing, night float rotations, and overall resident operative experience on ACS services. Prognostic and Epidemiological; Level III.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis

BackgroundWhile trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood. MethodsThe Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions. ResultsThe number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (β = 109.07, P ≤ .001) and revision (β = −13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111). ConclusionThe present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction.

To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams. A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration. A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p=0.963; p=0.467; p=0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p=0.006, Cohen d=0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p=0.001, Cohen d=0.67; Consistent ST: 51.6 min, p=0.013, Cohen d=0.61; Consistent CN: 44.5 min, p=0.031, Cohen d=0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p=0.940; p=0.174; p=0.935, respectively). Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs. 3 Laryngoscope, 133:2154-2159, 2023.