Experienced Surgeons Research Articles

The experiences of cardiovascular surgeons and nurses with mutual support through interprofessional collaboration in the intensive care unit.

The World Health Organization (WHO) emphasizes the need for radical approaches in its Global Patient Safety Action Plan, particularly in terms of interprofessional and multidisciplinary approaches. The plan highlights the importance of providing training on patient safety for all professionals, focusing on team and task-based strategies that include bedside and simulation education. TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is an educational programme developed to teach health care professionals on specific tools and strategies to enhance basic teamwork skills. Mutual support, one of the teamwork skills described in TeamSTEPPS®, involves team members assisting one another, providing and receiving feedback on performance, and advocating assertively when patient safety is threatened. The aim of this study was to explore the experiences of cardiovascular surgeons and nurses with mutual support through interprofessional collaboration in the intensive care unit (ICU) at Hacettepe University. The study employed a basic qualitative research design. The data were gathered through in-depth interviews and analysed with inductive content analysis in accordance with Elo and Kyngäs. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to describe and report the components of study design. We interviewed 13 participants: 6 surgeons and 7 nurses. Six themes were identified: mutual support, positiveness of working in a supportive environment, feedback, effective communication, patient safety and conflict resolution. The results of our study revealed that intra/inter-professional collaboration and mutual trust based on the variety of individual and workplace-related factors improved patient safety through individual motivation while monitoring and supporting each other in a positive environment, providing feedback and encouraging effective communication, patient advocacy and conflict resolution. Exploring the experiences, challenges and successes of health care workers in interprofessional collaboration is crucial. Understanding team dynamics, communication barriers and collaboration strategies can help promote more effective teamwork and contribute to the development of plans to improve the quality of patient care.

Operator Experience With Robot-Assisted Laparoscopic Rectal Resection and the Impact of Using an Extra Arm on Surgical Outcomes.

Although robot-assisted surgery has been rapidly gaining popularity in recent years, few reports have examined the impact of individual robotic arm movements on surgical outcomes. This study investigated the relationship between extra arm (EA) usage and experience of surgeons in robot-assisted surgery. A total of 176 robot-assisted rectal resections were performed by three surgeons from 2018 to 2022. Each surgeon's first 20 cases categorized in the Early group and the 21st-40th cases in the Late group. Sixty cases in the Early group and 60 cases in the Late group were included to compare patient background, EA motion, and surgical outcomes. More anastomoses were performed closer to the anus in the Late group (p = 0.001). Console time was significantly shorter in the Late group (196 min vs. 153 min, p = 0.020). EA injuries, improper grasping, and intraoperative problems (intraoperative bleeding, misidentification of layers) were significantly less frequent in the Late group (p = 0.001). As experience with robot-assisted surgery increases, appropriate and safe use of an EA was achieved, and operative time and intraoperative problems were reduced.

The Facial Rejuvenation Enhancing Cheek Lift (FRENCH LIFT), a Facelift Technique that Treats Sagging of the Anterior Column of the Face: A Single Surgeon's 10-year Experience with 1100 Operated Patients.

Most facelift techniques have limited effect on the nasolabial fold and the more medial part of the face. The facial rejuvenation enhancing cheek (FRENCH) lift can treat both jowl sagging and midface deflation by a monobloc vertical and oblique displacement of the anterior column of the face through an extended subcutaneous dissection. To explain the surgical technique and to show its efficacy on the nasolabial fold, jawline and infraorbital rim. We retrospectively included all patients operated by a single surgeon between 2014 and 2024. Data were collected and analyzed for patient demographics, outcomes and complications. In total, 1100 consecutive patients were included (53 males, 1047 females). Mean age was 58 (29-83) years. Primary facelift was performed in 968 patients, secondary in 132 patients. Associated procedures were performed in 679 cases (25 lipofillings, 509 blepharoplasties, 145 browlifts, 22 bichectomies). The complication rate was 7% (39 hematomas, 5 neuropraxias of the buccal branch, 6 neuropraxias of the mandibular branch, 7 infections, 26 skin necrosis). The FRENCH Lift is a safe and long-term effective facelift technique that allows the treatment of jowl fat sagging, nasolabial fold deepening and infraorbital rim hollowing by a vertical and oblique lifting of the more medial facial fat compartments. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prophylactic central lymph node dissection for low-risk papillary thyroid cancer-Impact on subsequent therapy.

For small papillary thyroid cancers (PTCs) with no lateral nodal involvement, American Thyroid Association guidelines recommend performing prophylactic central lymph node dissection (pCLND) if it influences further management. Our cohort study explored to what extent performing pCLND for small PTCs can de-escalate subsequent therapy including completion thyroidectomy and adjuvant radioactive iodine (RAI) ablation. Adults with T1, T2, and cN0 PTCs were identified from 42 centers across the prospectively maintained Australian and New Zealand Thyroid Cancer Registry (ANZTCR) between 2017 and 2023. Patients were excluded if they had clinical nodal involvement or distant metastases. Subsequent therapy and complication rates were compared between patients with and without pCLND. Out of 1290 patients with T1, T2, and cN0 PTCs (78% female and median age 53years), 660 (51%) received a total thyroidectomy and 630 (49%) received a hemithyroidectomy. Prophylactic CLND was performed for 477 patients (37%) and 36% uncovered occult lymph node metastases. After adjusting for differences in age, sex, and tumor characteristics, absence of lymph node metastasis after pCLND was independently associated with fewer completion thyroidectomies (adjusted relative risk [aRR]=0.65 and p=0.008) and reduced RAI ablation (aRR 0.55 and p<0.001). Additionally, pCLND was not associated with higher risks of recurrent laryngeal nerve injury (p=0.33), temporary hypocalcemia (p=0.21), or permanent hypoparathyroidism (p=0.48). In specialized settings across Australia and New Zealand, identifying negative lymph nodes from pCLND is associated with reduced completion thyroidectomies and RAI ablation amongst low risk cN0 PTCs. There were no additional complications rates when performed by experienced thyroid surgeons.

A right colectomy case study: transitioning to the Hugo RAS system with a novel 3-ports technique in experienced robotic colorectal practice.

Advancements in robotic technology have revolutionized general surgery, with new platforms and continuous improvements enhancing surgical procedures. Our unit adopted the Da Vinci Si model in 2012 and later the X model for various abdominal surgeries. In early 2023, we integrated the Hugo RAS system by Medtronic into our practice following comprehensive training. This study examines the transition of experienced robotic surgeons from the Da Vinci platform to the Hugo RAS system, focusing on robotic right hemicolectomy. We conducted a retrospective analysis of consecutive adult patients who underwent robotic right hemicolectomy using the Da Vinci X and Hugo RAS systems. Outcomes from the latest seven cases with the Da Vinci X system were compared to the initial seven cases with the Hugo RAS system. The baseline characteristics of the two groups were comparable, with no significant differences in age, sex, comorbidities, ASA score, or BMI. Operative times showed a trend towards being shorter with the Da Vinci X (127 ± 30min) compared to the Hugo RAS (163 ± 43min), but this was not statistically significant (p = 0.2). Other measures, including blood loss, anastomotic configuration, and length of hospital stay, were similar. Two non-surgical postoperative complications occurred in the Hugo RAS group, with no complications in the Da Vinci X group. There were no 30-day readmissions or reoperations in either group. Experienced robotic surgeons can seamlessly transition to the Hugo RAS system for right hemicolectomy, achieving comparable outcomes to the Da Vinci system.

Dorsal cortex line is more reliable than transepicondylar axis for rotation in revision total knee arthroplasty with severe bone loss.

The transepicondylar axis is a well-established reference for the determination of femoral component rotation in total knee arthroplasty (TKA). However, when severe bone loss is present in the femoral condyles, rotational alignment can be more complicated. There is a lack of validated landmarks in the supracondylar region of the distal femur. Therefore, the aim of this study was to analyze the correlation between the surgical transepicondylar axis (sTEA) and the suggested dorsal cortex line (DCL) in the coronal plane and the inter- and intraobserver reliability of its CT scan measurement. A total of 75 randomly selected CT scans were measured by three experienced surgeons independently. The DCL was defined in the coronal plane as a tangent to the dorsal femoral cortex located 75 mm above the joint line in the frontal plane. The difference between sTEA and DCL was calculated. Descriptive statistics and angulation correlations were generated for the sTEA and DCL, as well as for the distribution of measurement error for intra- and inter-rater reliability. The external rotation of the DCL to the sTEA was a mean of 9.47° (SD 3.06°), and a median of 9.2° (IQR 7.45° to 11.60°), with a minimum value of 1.7° and maximum of 16.3°. The measurements of the DCL demonstrated very good to excellent test-retest and inter-rater reliability coefficients (intraclass correlation coefficient 0.80 to 0.99). This study reveals a correlation between the sTEA and the DCL. Overall, 10° of external rotation of the dorsal femoral cortical bone to the sTEA may serve as a reliable landmark for initial position of the femoral component. Surgeons should be aware that there are outliers in this study in up to 17% of the measurements, which potentially could result in deviations of femoral component rotation.

Principles of Stereotactic Surgery.

Stereotactic procedures are used to manage a diverse set of patients across a variety of clinical contexts. The stereotactic devices and software used in these procedures vary between surgeons, but the fundamental principles that constitute safe and accurate execution do not. The aim of this work is to describe these principles to equip readers with a generalizable knowledge base to execute and understand stereotactic procedures. A combination of a review of the literature and empirical experience from several experienced surgeons led to the creation of this work. Thus, this work is descriptive and qualitative by nature, and the literature is used to support instead of generate the ideas of this framework. The principles detailed in this work are categorized based on 5 clinical domains: imaging, registration, mechanical accuracy, target planning and adjustment, and trajectory planning and adjustment. Illustrations and tables are used throughout to convey the concepts in an efficient manner. Stereotactic procedures are complex, requiring a thorough understanding of each step of the workflow. The concepts described in this work enable functional neurosurgeons with the fundamental knowledge necessary to provide optimal patient care.

Surgical and oncological outcomes of salvage radical prostatectomy after focal therapies: a matched-pair analysis.

To determine the surgical and oncologic outcomes of salvage radical prostatectomy (sRP) after FT failure. Patients who consecutively underwent primary RP or sRP after FT failure between 2008 and 2022 were retrospectively selected. Primary or sRP were performed with either a robot-assisted or open approach. All surgeries were performed by surgeons with experience of ≥ 500 cases. Biochemical recurrence-free survival (BFS), intra- and postoperative surgical and functional outcomes were assessed. To evaluate the impact of surgical setting, propensity score (PS) matching was performed. 80 patients received sRP. Outcomes were analyzed using PS-matched cohorts (203 RPs vs. 68 sRPs). After a median follow-up of 25.4 months, sRP and RP had equal BFS (24mo-BFS: 72.4% vs. 76.0% (p = 0.8)). No statistically significant differences were found between sRP and RP in terms of median operative time (OT) (171min vs. 168min), estimated blood loss (EBL) (500ml vs. 500ml), length of hospital stay (LOS) (7 days vs. 7 days) and time to catheter removal (11 days vs. 11 days) and 1-year continence rates (all standardized mean differences ≤ 0.1). The main limitation is the retrospective study design. In the hands of experienced surgeons, sRP after FT offered comparable surgical and oncologic outcomes as RP in a primary setting.

Surgeon experience affects perioperative pain in cats undergoing elective ovariohysterectomy: a randomized clinical trial.

This study aimed to compare the outcomes between surgeries performed by either experienced or inexperienced surgeons by assessing intraoperative nociception and perioperative analgesia. 16 healthy, client-owned female cats were randomly allocated into 2 groups of 8: one undergoing surgery by an experienced surgeon (GES group) and the other by inexperienced surgeons (GIS group). Both groups received IM premedication with acepromazine (0.05 mg/kg) and methadone (0.3 mg/kg). After 20 minutes, venipuncture and induction with propofol (dose-response, IV) were performed. Maintenance was achieved with inhaled isoflurane. Intraoperative vital parameters were monitored, and fentanyl (2.5 µg/kg, IV) was administered as rescue analgesia when needed. Postoperatively, pain was assessed with a visual analog scale and the multidimensional pain scale of the Universidade Estadual Paulista in Botucatu; morphine (0.2 mg/kg, IM) was used for rescue analgesia, as necessary. In the GIS group, significant increases in heart rate and systolic blood pressure were noted during surgery, especially during pedicle clamping. Respiratory rate and end-tidal isoflurane levels were higher in the GIS group at specific surgical stages. Survival analysis indicated that the GIS group had a greater need for fentanyl. Postoperative pain scores were generally low, but a higher proportion of GIS cats required rescue analgesia. Surgeon experience influences intraoperative parameters and fentanyl consumption. Inexperienced surgeons contribute to increased postoperative pain and poorer wound healing outcomes in cats undergoing elective ovariohysterectomy. Ovariohysterectomy is a common procedure in veterinary practice, and surgical expertise significantly impacts pain management and recovery. Yet, its effects have been underexplored, potentially compromising animal welfare.

The Use of Reinforced Ovine Mesh in Implant Breast Reconstruction: Equivalent Outcomes to Human Acellular Dermal Matrices and More Cost-effective.

The use of "mesh" in implant-based reconstruction is widespread, with both acellular dermal matrices (ADMs) and extracellular matrices (ECMs) being used, especially in prepectoral device placement. This study compared Ovitex (ovine ECM) versus human cadaveric ADMs to determine safety profiles and cost-effectiveness. A single surgeon's longitudinal experience with 2-stage, immediate tissue expander breast reconstruction from 2018 to 2023 was analyzed. Patients with AlloDerm and Cortiva (human ADM) were compared with those receiving Ovitex, and 90-day complications were analyzed by chi-squared and analysis of variance. Costs of each mesh were tabulated based on available market data. Patient demographics were comparable. Of 127 patients, 85 received ovine ECM (163 breasts) and 42 received cadaveric ADM (81 breasts). No significant difference between the groups for complications requiring return to the operating room (12.7% ovine vs 14.8% human (P = 0.31) or minor complications (9.8% ovine vs 7.4% human, P = 0.34). There was no difference between reconstructive success and failure between the 2 groups (P = 0.066). The cost of Ovitex was 24%-38% cheaper than Cortiva and AlloDerm, respectively. In this longitudinal, single-surgeon study of 2 different types of meshes in 2-stage expander implant breast reconstruction, we found ovine multilaminated reinforced extracellular matrix (Ovitex) was comparable in outcomes with human acellular dermal matrices (AlloDerm and Cortiva). Ovine mesh was considerably cheaper. Multiple factors determine which mesh should be chosen for implant breast reconstruction. This study supports the use of Ovitex as a cost-effective substitute for human acellular dermal matrices in implant breast reconstruction.

Closed Reduction Followed by Percutaneous Fixation of Acute Femoral Neck Fractures in Young Adults: A Retrospective Cohort Study

OBJECTIVES: To evaluate the surgical outcomes of femoral neck fractures (FNF) in young adults treated with a closed reduction technique because it pertains to reduction quality, rates of union, and risk factors for complication. METHODS: Design: Retrospective cohort study with radiograph and electronic medical record review. Setting: Level 1 Swiss Trauma Center. Patient Selection Criteria: Between 2012 and 2021, young adults with isolated FNF (AO/OTA 31-B1) treated with percutaneous internal fixation were selected. Exclusion criteria were open reduction technique, age older than 65 years or younger than 16 years, pathologic fractures, and associated femoral head or shaft fractures. Outcome Measures and Comparisons: Primary outcome was quality of reduction, as assessed by 3 experienced trauma surgeons' evaluation of intraoperative and/or first postoperative radiographs using the overall impression, the Garden alignment index, and Lowell criteria. In addition, clinical outcomes, conversion to arthroplasty, and complications after closed reduction and fixation of femoral neck fractures were reviewed. RESULTS: A total of 54 patients with a median interquartile range age of 57.5 (48–60) years were included. Among them, 22 (41%) were women and 32 (59%) were men. The closed reduction technique demonstrated satisfactory reduction results in up to 87% of cases. Major complications occurred in 19%, with 17% requiring conversion to total hip arthroplasty. Unacceptable or borderline acceptable reduction quality correlated significantly with the need for later conversion (P = 0.03). CONCLUSIONS: The study supported the use of the closed reduction technique for acute FNF in patients younger than 65 years, achieving satisfactory reduction results in up to 87% of cases with comparable complication rates to treatment of young femoral neck fractures with open reduction. Furthermore, it underscored the significance of the surgeon's overall impression of reduction quality, alongside the established reduction criteria, the Garden alignment index, and Lowell criteria, in evaluating the quality of the reduction. In addition, risk of conversion to total hip arthroplasty was associated with worse closed reduction quality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Determinants of Salary Variation and the Gender Pay Gap: A Survey of the American Association of Hip and Knee Surgeons (AAHKS) Surgeon Member Workforce

BackgroundThe increased emphasis on reimbursement, diversity, and burnout in hip and knee arthroplasty necessitates a foundational understanding of the surgeon workforce. The purpose of the study was to cross sectionally survey a representative sample of the AAHKS surgeon membership on the subject of salary, practice patterns, and demographic factors to establish a baseline framework for future advocacy efforts and initiatives. MethodsAn online survey was sent to AAHKS members between December 20, 2022 and January 19, 2023. Surgeon demographic data, experience, practice geography and type, and annual case volume were solicited. Univariate and multivariate analyses were performed to describe the association of respondent characteristics with reported salary directly from patient care, as well as indirect revenue streams. ResultsA total of 730 AAHKS members responded to the survey. The largest proportion of surgeons performed 251-400 cases annually (36%); 81% (n = 592) and 93% (n = 679) of respondents identified as white and male, respectively. Case volume was the primary determinant for surgeon salary, followed by practice type, years in practice, and gender. After controlling for confounding variables, multivariate analyses revealed the direct salary of women surgeons was 14.4% less than men [95% confidence interval, 0.4%-28.3%]. When considering indirect revenue, the gender pay gap widened. Salary was not associated with reported hours worked per week, geographic location, or ethnicity. ConclusionsSalary is an important but underdiscussed subject that reflects the realities of our culture and value system in medicine. A direct relationship between salary and modifiable variables like case volume is clear. However, after controlling for confounders, women arthroplasty surgeons still earn 86 cents on the dollar compared to their male colleagues from direct surgical revenue.

Comparative Analysis of Large Language Models and Spine Surgeons in Surgical Decision-Making and Radiological Assessment for Spine Pathologies

AimThis study aimed to investigate the accuracy of large language models (LLMs), specifically ChatGPT and Claude, in surgical decision-making and radiological assessment for spine pathologies compared to experienced spine surgeons. MethodsThe study employed a comparative analysis between the LLMs and a panel of attending spine surgeons. Five written clinical scenarios encompassing various spine pathologies were presented to the LLMs and surgeons, who provided recommended surgical treatment plans. Additionally, MRI images depicting spine pathologies were analyzed by the LLMs and surgeons to assess their radiological interpretation abilities. Spino-pelvic parameters were estimated from a scoliosis radiograph by the LLMs. ResultsQualitative content analysis revealed limitations in the LLMs' consideration of patient-specific factors and the breadth of treatment options. Both ChatGPT and Claude provided detailed descriptions of MRI findings but differed from the surgeons in terms of specific levels and severity of pathologies. The LLMs acknowledged the limitations of accurately measuring spino-pelvic parameters without specialized tools. The accuracy of surgical decision-making for the LLMs (20%) was lower than that of the attending surgeons (100%). Statistical analysis showed no significant differences in accuracy between the groups. ConclusionThe study highlights the potential of LLMs in assisting with radiological interpretation and surgical decision-making in spine surgery. However, the current limitations, such as the lack of consideration for patient-specific factors and inaccuracies in treatment recommendations, emphasize the need for further refinement and validation of these AI models. Continued collaboration between AI researchers and clinical experts is crucial to address these challenges and realize the full potential of AI in spine surgery.

A Decade of Prostate Intervention Robots: Systematic Review

Abstract: The image-guided prostate intervention robot can assist surgeons in performing minimally invasive intervention procedures. It has the advantage of overcoming the disadvantages of a traditional surgeon's hand tremor and dependence on the need for an experienced surgeon, improving the intervention precision, and reducing the hazards caused by normal soft tissues due to surgical precision errors compared to traditional intervention procedures. In the design of prostate intervention robots, structural design, materials, actuators, and compatibility issues should be considered. Based on the above considerations, a representative literature of the last decade was selected for review. Patents and articles on image-guided prostate intervention robots published in the last 10 years (2013-2023)were searched in several electronic databases, focusing on keywords (structural design, puncture accuracy, image compatibility, actuator) for screening. We retrieved a total of 26 prostate intervention robots guided by different images, classified them by US, MRI, MRI-US and CT, selected representative robots guided by different image modalities for review and tabulated them for comparison, and finally boldly predicted that the future direction will be prostate robots guided by MRI-US images. Image-guided prostate intervention robots can improve the deficiencies of conventional intervention procedures. In the future how to improve the intervention accuracy will be the primary problem of all intervention robots, through structural design, materials, actuators, and image compatibility issues have been improved.

Patient Satisfaction After 3D Nipple-Areola Complex Tattooing: A Case Series of Hispanic Women Following Breast Reconstruction Surgery.

Breast cancer is a prevalent cancer worldwide, leading many women to undergo mastectomy and breast reconstruction surgery. Nipple-areolar complex (NAC) reconstruction is critical in achieving aesthetic and psychological satisfaction. Recently, three-dimensional (3D) nipple-areola tattooing has become an alternative for this purpose. This study evaluates patient-reported outcomes on satisfaction among Hispanic women who underwent NAC reconstruction using 3D tattooing after breast reconstruction. Data were collected from a retrospective database in multicentric academic settings between 2014 and 2024. Participants included Hispanic women aged 32 to 60 years who received various NAC reconstruction techniques. Follow-up was conducted no more than six months after surgery, utilizing the Breast-Q version 2.0 questionnaire to measure satisfaction in two groups Group 1, in which patients received alternative NAC reconstruction methods, and Group 2, which had 3D nipple-areola tattooing. Patients who underwent 3D nipple-areola tattooing (Group 2) demonstrated increased psychosocial well-being, with a mean score of 84.73 (± 8.56). Regarding surgeon experience, Group 2 achieved a mean score of 86.21 (± 10.33), which was lower than Group 1 mean of 88.70 (± 10.78). Notably, Group 2 expressed greater satisfaction with nipple reconstruction, with a mean score of 3.73 (± 0.44) compared to Group 1 with a mean of 3.48 (± 0.65). The findings indicate that 3D nipple-areola tattooing may enhance aesthetic outcomes of the NAC and psychosocial well-being in Hispanic women. This highlights the importance of incorporating unique techniques in breast reconstruction and the need for a multidisciplinary approach.

How Accurate and Effective Are Non-image-guided Thumb Basal Joint Injections When Performed by Experienced Fellowship-trained Hand Surgeons?

Corticosteroid injections are widely used for treating thumb carpometacarpal (CMC) arthritis, yet the accuracy of non-image-guided injections in expert hands is uncertain, with prior studies reporting intraarticular placement in about 60% of thumbs when performed by physicians with different levels of training. Despite their common use, there is a need to assess both the accuracy and the short-term clinical efficacy of these injections, particularly when performed without image guidance by fellowship-trained hand surgeons. (1) What is the accuracy of thumb CMC injections performed without image guidance by fellowship-trained hand surgeons in an office setting? (2) What is the short-term efficacy of thumb CMC injections performed without image guidance? We prospectively enrolled 33 patients with a mean ± SD age of 63 ± 12 years, 76% (25) of whom were female, with symptoms of basal joint arthritis that persisted despite conservative treatment, and we administered 1.5-mL corticosteroid injections without image guidance. We used descriptive statistics to analyze the outcomes, which included VAS, QuickDASH (Q-DASH), and Thumb Disability Examination (TDX) scores. Minimum clinically important differences (MCIDs) were defined as 0.9 points for the VAS, 18 points for Q-DASH, and 17 points for TDX. Of the 33 injections analyzed, 79% (26) were intraarticular. At 6 weeks, patients reported a mean improvement of 22 points in QuickDASH, 24 points in TDX, and 4 points in VAS scores. Importantly, 73% (24 of 33), 55% (18 of 33), and 82% (27 of 33) of the patients achieved the MCID in the patient-reported outcomes, respectively, suggesting that even without image guidance, corticosteroid injections can provide effective short-term relief for thumb CMC arthritis. We found that about 79% of injections were placed intraarticularly, which was comparable with the findings of previous studies using image guidance, and provided meaningful improvements in pain and function for 6 weeks. These findings suggest that for experienced fellowship-trained hand surgeons, non-image-guided injections remain a viable option. Future studies should explore long-term outcomes and the potential role of adjunctive treatments such as antiinflammatory medications and splinting to enhance patient care. Level II, therapeutic study.

Extraperitoneal Open Radical Cystectomy: A New Standard in Frail Patients with Muscle-Invasive Bladder Cancer?

Background/Objectives: Radical cystectomy (RC) represents one of the most complex and morbid surgical procedures in the field of Urology. Extraperitoneal open RC has emerged as an alternative to the traditional transperitoneal approach for the treatment of muscle-invasive bladder cancer. Frailty is one of the most important risk factors for perioperative morbidity and mortality, and this category of patients can benefit the most from the extraperitoneal approach. The purpose of this study was to evaluate the feasibility and the safety of extraperitoneal open RC in our experience; Methods: We retrospectively collected the data of 75 frail patients who underwent an extraperitoneal open RC, performed by a single experienced surgeon. We assessed their frailty status using the simplified frailty index (sFI). We recorded data regarding general characteristics, intraoperative, pathological, and postoperative complications, and mortality (within 90 days); Results: We analyzed 61 males and 14 females with an sFI equal to or higher than 3. The median age was 77 years. Fifty-one patients had an ASA score of 3 or more. Sixty procedures were with radical intention, while fifteen were palliative. Cutaneous ureterostomy was performed in 70 cases and extraperitonized ileal conduit in five cases. The median operative time was 150 min. The median blood loss was 400 mL. The median time to flatus was 2 days. The median postoperative stay was 7 days. Thirteen patients had Clavien-Dindo III or IV complications. Two patients died in first 90 days postoperatively; Conclusions: The extraperitoneal open RC in frail patients was demonstrated to be a feasible and safe alternative approach in definitive treatment or a palliative setting in our experience.

Radiographic Assessment of Total Knee Arthroplasty Alignment with and without Accelerometer-Based Navigation at a Resident Training Institution.

Malalignment and lack of surgeon experience are cited as risk factors for prosthetic failure and the need for subsequent revision surgery in total knee arthroplasty (TKA). Various Conventional (CON) and Computer Assisted Surgical (CAS) methods have been developed to try and prevent malalignment and limit outliers. One of these methods is through an accelerometer-based CAS (aCAS) which intra-operatively helps determine the angulation and amount of resection necessary to restore alignment in TKA. The purpose of this study was to determine the number of TKA alignment outliers in TKA's performed both with CON and aCAS methods at a single training institution in cases that trainees were involved in. In this retrospective single center study, radiographic analysis of 150 primary TKAs performed at our training institution was performed. The medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior slope angle (PSA) were evaluated on immediate post-operative radiographs of 75 aCAS and 75 CON knees. Outlier measurements were defined as DFA outside of 5° ±3° valgus; PTA >±3° from neutral axis; and PSA outside 0-7° for Cruciate Retaining (CR) and 0-5° for Posterior Stabilized (PS) implants. Data was analyzed using chi-squared, ANOVA and Student's t-tests. There was no significant difference found between these two groups in the total number of outliers (8% aCAS versus 9.8% CON, p=0.508). Additionally, there was also no significant difference found for any of the radiographic measurements independently; DFA (8% versus 8%, p=1.00), PTA (4% versus 9%, p=0.184), and PSA (12% versus 12%, p=1.00), when comparing aCAS and CON TKA's. Primary TKAs performed at a single training institution demonstrated no significant difference between aCAS and CON methods in the total number of outliers or in the number of outliers for each postoperative radiographic measurement. This study would suggest that there is no advantage in limiting outliers when utilizing aCAS for TKAs at training institutions in cases that trainees are involved in.

Soft Tissue Sarcoma with Lower Limb Impairment: Development of a Specific Rehabilitation Protocol Based on Demolitive and Reconstructive Surgery Types

Background/Objectives: Soft tissue sarcomas (STSs) are extremely uncommon tumors with a high rate of local recurrence that often require very demolitive surgery. The aim of our study is to propose a specific rehabilitation protocol for patients with STSs, based on the kind of demolition and reconstructive surgery performed, and evaluate its effects. Methods: The protocol was developed on the basis of the clinical experiences of physiatrists and surgeons, as well as data from the literature, recommending timelines for postural steps, verticalization, walking, and therapeutic exercises, in accordance with wound healing times and in order to prevent complications from disuse and immobility. The modified Barthel Index Scale (mBI), the Numeric Rating Scale (NRS), the Adapted Patient Evaluation Conference System (APECS), and the 10 Meter Walk Test (10 MWT) were used to clinically evaluate patients before and after the rehabilitation treatment. Results: Thirty-one patients with primary STSs were enrolled. Following the rehabilitation program, we found a statistically significant improvement in mBI (p &lt; 0.001), APECS (p ≤ 0.001), and NRS (p = 0.001). In a subgroup of patients (n = 18) assessed with the 10 MWT, a statistically significant increase in walking speed was observed (p = 0.012). Conclusions: Patients who completed rehabilitation following the proposed protocol, customized according to the surgical intervention type, demonstrated marked improvements in motor performance, ability in daily activities, walking, and pain. The proposed protocol can assist the multidisciplinary team of surgeons, oncologists, and rehabilitators in maintaining alignment on patient management, thereby ensuring clear indications regarding the activities that patients can and cannot undertake during the recovery period.

Learning Curves and Surgical Outcomes of Laparoscopic Sleeve Gastrectomy Performed by an Attending Surgeon and Trainee Surgeons.

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed procedure for bariatric and metabolic surgery. However, few reports exist concerning the learning curves and surgical outcomes of LSG among trainee surgeons. This study aimed to investigate the learning curves and surgical outcomes of LSG for one attending surgeon and trainee surgeons. In this study, 90 patients who underwent LSG were retrospectively evaluated. Surgical learning curves for the attending and the trainees were assessed via cumulative sum (CUSUM) analysis. After the attending reached the learning phase, the trainees performed LSG under the guidance of the attending. Surgical and postoperative outcomes were compared retrospectively. The CUSUM plot of the attending peaked in the 16th case, began to decrease and reached a plateau in the 49th case. Therefore, we defined the attending in Phase I up to 16 LSGs (n = 16; learning phase), in phase II between 27 and 48 LSGs (n = 22; acquisition phase), and in Phase III from 49 or more LSGs (n = 29; plateau phase). The CUSUM of the trainees' operative time declined from the beginning. The median operative time was significantly shorter in the trainees than in the attending in Phase I (184 [146-266] vs. 161 [111-255], p < 0.01). %EWL was significantly better in the patients of the trainees than in those of the attending (92.4 ± 35.7 vs. 71.0 ± 28.7, p < 0.01). These results indicate that trainees could perform LSG in a stable manner. Under the guidance of experienced surgeons, LSG can be safely performed by trainees without prolonged surgical time.