Surgical Outcome Measures Research Articles

Measuring and Improving Emotional Intelligence in Surgery: A Systematic Review.

Evaluate how emotional intelligence (EI) has been measured among surgeons and to investigate interventions implemented for improving EI. EI has relevant applications in surgery given its alignment with nontechnical skills. In recent years, EI has been measured in a surgical context to evaluate its relationship with measures such as surgeon burnout and the surgeon-patient relationship. A systematic review was conducted by searching MEDLINE, EMBASE, CINAHL, and PSYCINFO databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MeSH terms and keywords included "emotional intelligence," "surgery," and "surgeon." Eligible studies included an EI assessment of surgeons, surgical residents, and/or medical students within a surgical context. The initial search yielded 4627 articles. After duplicate removal, 4435 articles were screened by title and abstract and 49 articles proceeded to a full-text read. Three additional articles were found via hand search. A total of 37 articles were included. Studies varied in surgical specialties, settings, and outcome measurements. Most occurred in general surgery, residency programs, and utilized self-report surveys to estimate EI. Notably, EI improved in all studies utilizing an intervention. The literature entailing the intersection between EI and surgery is diverse but still limited. Generally, EI has been demonstrated to be beneficial in terms of overall well-being and job satisfaction while also protecting against burnout. EI skills may provide a promising modifiable target to achieve desirable outcomes for both the surgeon and the patient. Future studies may emphasize the relevance of EI in the context of surgical teamwork.

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Auricular Surgery: A Systematic Review.

The utilization of an assessment instrument that successfully analyzes validated outcome measures for auricular surgery is important for advancing evidence-based medicine. To systematically review postsurgical scar assessment instruments and outcome measures after auricular surgery to assess if any individual or combination of 2 assessment instruments encompass all relevant, validated auricular outcome measures. Two systematic reviews were conducted using the PubMed/MEDLINE and Ovid databases: one for postauricular surgical outcome measures and another for postsurgical scar assessment instruments. Auricular outcome measure articles were selected for inclusion if they included at least one auricular-specific validated outcome measure, and assessment tool articles were included if they referenced one or more specific tool(s) specifically designed to assess postsurgical scars. Assessment tools were evaluated based on which outcome measures each covered. There was no single postsurgical scar assessment instrument or combination of 2 instruments that covered all outcome measures within the 5 different categories (psychosocial well-being, functional, objective appearance, subjective appearance, and clinical-related outcomes) after auricular surgery. None of the instruments measured functional outcomes, such as the ability to wear glasses and hearing outcomes. There is currently no existing postsurgical scar assessment instrument that covers all outcome measures after auricular surgery.

A perceptual outcome measure of velopharyngeal function based on the Cleft Audit Protocol for Speech-Augmented (CAPS-A VPC-Sum): Validation through a speech osteotomy study.

The status of the velopharyngeal mechanism can be inferred from perceptual ratings of specified speech parameters. Several studies have proposed the measure of an overall velopharyngeal composite score based on these perceptual ratings and have reported good validity. The Cleft Audit Protocol for Speech-Augmented (CAPS-A) is a validated and reliable perceptual framework for the assessment of cleft speech and velopharyngeal function used by all Regional Cleft Services in the UK and Ireland. An overall velopharyngeal composite summary score based on the CAPS-A would serve as an important surgical outcome measure of speech. To develop and validate a velopharyngeal composite summary score based on perceptual ratings made on the CAPS-A (CAPS-A VPC-Sum) using data from a maxillary osteotomy (MO) study. There were two surgical groups: a cleft lip and palate (CLP) (N = 20) group and a non-CLP group (N = 10), and a normal control group (N = 20). Participants in groups 1 and 2 were seen for perceptual and instrumental assessments of speech and velopharyngeal function preoperatively (T1), 3 months (T2) and 12 months (T3) postoperatively. Perceptual speech data were collected and rated by independent listeners using CAPS-A. Moderate to strong interrater reliability for perceptual data (rs = 0.503-1.000, all p < 0.01) and strong to very strong reliability for videofluoroscopic measurements (rs = 0.746-0.947) were found. Construct validity of the CAPS-A VPC-Sum was shown by an increase in postoperative scores for the CLP group only ϰ2 (2) = 9.769, p = 0.008 and significant differences between the CLP and the other two groups at T2 and T3 using independent t-tests. Convergent and divergent validity was indicated by a positive moderate correlation with related parameters (e.g., hypernasality rs = 0.869, p < 0.01) and a weak correlation with unrelated parameters (e.g., amount of forward advancement rs = 0.160, p = 0.526). Criterion validity was found by a moderate correlation between closure ratio rs = -0.541, p = 0.020 and CAPS-A VPC-Sum. A velopharyngeal composite score based on perceptually rated parameters serves as an important surgical speech outcome measure. The CAPS-A VPC-Sum is a useful, reliable and valid outcome measure of velopharyngeal function. There are added positive implications for other clinicians using geographically and language-specific adapted versions of the CAPS-A internationally. What is already known on this subject Velopharyngeal composite scores based on perceptually rated speech parameters have been shown to have both clinical and research utility, serving as a useful surgical outcome measure. However, such a composite score must be specifically validated on the perceptual speech framework upon which it is based, as there are differences in measurement methods and terminology across cleft speech perceptual frameworks internationally. What this paper adds to existing knowledge The CAPS-A is a nationally used tool in the UK and Ireland for audit and research purposes with validated and adapted international versions. This paper reports on the validation of the derived velopharyngeal composite score measure based on the CAPS-A and an English-speaking sample, providing evidence of its validity through a speech osteotomy study. What are the potential or actual clinical implications of this work? This work provides CLP teams who use CAPS-A with a validated surgical speech outcome measure of velopharyngeal function. It has positive implications also for adapted versions of the CAPS-A internationally.

Total extra peritoneal inguinal hernia repair: a single-surgeon preliminary findings report.

Inguinal hernia repair is one of the most frequent operations in general surgery. Various techniques have been used to repair inguinal hernias since the first reconstructive technique described by Bassini in 1887. In 1989 Lichtenstein reported a new technique: tension free inguinal hernia repair. Laparoscopic inguinal hernia repair was introduced in the early 1990s, and soon also became popular. Literature has shown the benefits of laparoscopy (in comparison with open repair) to be mostly related to the more minimally invasive nature of the surgery, having lower wound infection rates, faster recovery, and less postoperative pain. To evaluate our totally extraperitoneal (TEP) inguinal hernia repair initial results and compare them to literature data. In a prospective review and analysis, we examined 61 cases of hernia repair via laparoscopy (specifically TEP), performed by a single surgeon, between April 2019 and December 2019 at the Kaspela University Hospital in Plovdiv. The centre's Institutional Review Board approved the study with no specific consents required due to the retrospective, minimal risk nature of the study. The routine informed consent required by the National Insurance Fund has been considered sufficient for the study objectives.The surgical outcome measures included operating time (hours/minutes), conversion, peritoneal injury, surgical emphysema; and the clinical outcome measures included postoperative seroma, post-operative infection, and post-operative chronic groin pain. Inguinal pain on discharge was characterized as mild by 56 (96.55%) patients and moderate by 2 (3.44%), there were no patients describing the pain as severe. The most frequently reported postoperative complications were annoyance and discomfort (10.34%), swelling (6.9%), seroma (3.44), hematoma (1.72%), paresthesia 1.72% (1); however, only those with seromas required special treatment. Limitations of the present study include the relatively small number of patients, all cases were operated on by a single surgeon and short postoperative follow-up period, but we are sharing our initial six months results. These results demonstrate that laparoscopic TEP inguinal hernia repair without mesh fixation is a reliable technique, which can reduce postoperative morbidity when applied by experienced surgeons.

Clinical experience of using virtual 3D modelling for pre and intraoperative guidance during robotic-assisted partial nephrectomy

Objective: Surgical planning for robotic-assisted partial nephrectomy is widely performed using two-dimensional computed tomography images. It is unclear to what extent two-dimensional images fully simulate surgical anatomy and case complexity. To overcome these limitations, software has been developed to reconstruct three-dimensional models from computed tomography data. We present the results of a feasibility study, to explore the role and practicality of virtual three-dimensional modelling (by Innersight Labs) in the context of surgical utility for preoperative and intraoperative use, as well as improving patient involvement. Methods: A prospective study was conducted on patients undergoing robotic-assisted partial nephrectomy at our high volume kidney cancer centre. Approval from a research ethics committee was obtained. Patient demographics and tumour characteristics were collected. Surgical outcome measures were recorded. The value of the three-dimensional model to the surgeon and patient was assessed using a survey. The prospective cohort was compared against a retrospective cohort and cases were individually matched using RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines) scores. Results: This study included 22 patients. Three-dimensional modelling was found to be safe for this prospective cohort and resulted in good surgical outcome measures. The mean (standard deviation) console time was 158.6 (35) min and warm ischaemia time was 17.3 (6.3) min. The median (interquartile range) estimated blood loss was 125 (50–237.5) ml. Two procedures were converted to radical nephrectomy due to the risk of positive margins during resection. The median (interquartile range) length of stay was 2 (2–3) days. No postoperative complications were noted and all patients had negative surgical margins. Patients reported improved understanding of their procedure using the three-dimensional model. Conclusion: This study shows the potential benefit of three-dimensional modelling technology with positive uptake from surgeons and patients. Benefits are improved perception of vascular anatomy and resection approach, and procedure understanding by patients. A randomised controlled trial is needed to evaluate the technology further. Level of evidence: 2b

Inguinal hernia mesh is safe in 1720 patients

There is substantial media and patient interest in the safety of mesh for hernia repair. However, there is a lack of data regarding health-related quality of life (HRQOL) outcomes in patients who undergo inguinal hernia repair (IHR) with mesh. The purpose of this study is report short and long-term postoperative quality of life outcomes in patients following IHR with mesh. We analyzed outcomes of 1720 patients who underwent IHR with mesh between 2008 and 2019 at a single institution from a prospectively maintained quality database. All surgeries were performed by four board-certified surgeons. HRQOL outcomes were measured using the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS) surveys that were administered preoperatively, 3weeks, 6months, 1, 2, and 5years postoperatively. Survey responses were summarized as mean with standard deviation or frequency with percentage. Postoperative SOMS scores were compared to preoperative scores using the two-tailed paired t test with a significance level of p < 0.05. One (0.1%) patient experienced a mesh infection postoperatively. In terms of complications, 159 (9.2%) developed a seroma, 31 (1.8%) a hematoma, and 36 (2.1%) patients experienced a recurrence. SOMS Pain Impact, SOMS Pain Quality, and SOMS Pain visual analog scale at 3weeks, 6months, 1year, 2years, and 5years were all improved from preoperative (all p < 0.05). At 5years postoperatively, only 3.9%, 3.2%, and 3.1% of patients reported severe or disabling sensation of mesh, pain, and movement limitations, respectively. Inguinal hernia repair with mesh results in a low rate of complications. A minority of patients had severe or disabling symptoms at 5-year follow-up and generally reported improvements in pain impact and quality in long-term follow-up.

Outcome Squares Integrating Efficacy and Safety, as Applied to Functioning Pituitary Adenoma Surgery.

Context Transsphenoidal surgery is standard care in the treatment of hormone-secreting pituitary adenomas. Current clinician-reported surgical outcome measures are one-dimensional, typically focusing primarily on complete or partial resection, and secondarily on complication rates. However, outcomes are best reflected by the delicate balance of efficacy and complications at patient level.ObjectiveThis study proposes a novel way to classify and report outcomes, integrating efficacy and safety at the patient level.MethodsRetrospective chart review of all pure endoscopic transsphenoidal surgical procedures for acromegaly, Cushing’s disease, and prolactinoma between 2010 and 2018 in a single tertiary referral center. We present our results in a classic (remission and complications separate) and in a novel outcome square integrating both outcomes, focusing on intended and adverse effects (long-term complications). This resulted in 4 outcome groups, ranging from good to poor. We use this approach to present these outcomes for several subgroups.ResultsA total of 198 surgical procedures were included (44 reoperations). Remission was achieved in 127 operations (64%). Good outcome was observed after 121 (61%), and poor outcome after 6 (3%) operations. When intended effect of surgery was applied (instead of remission), good outcome as intended was achieved after 148 of 198 surgeries (75%) and poor outcome after 4 (2%).ConclusionQuality of a surgical intervention can be presented in 4 simple categories, integrating both efficacy and safety with flexibility to adapt to the individualized situation at patient, disease, and surgical strategy and to the outcome of interest.

Impact of bilateral ureteral reimplantation at the time of complete primary repair of bladder exstrophy on reflux rates, renogram abnormalities and bladder capacity

Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity. An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity. A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p=0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p=0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p=0.016). After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation. BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient.

Predictors of chronic pain after laparoscopic inguinal hernia repair

BackgroundMultiple studies have analyzed predictors for chronic pain after open hernia repair. The purpose of this study is to determine which factors predict the development of chronic pain after a laparoscopic inguinal hernia repair. MethodsWe identified patients who underwent laparoscopic inguinal hernia repair between 2008 and 2020 at a single institution. Quality of life was measured using the Surgical Outcomes Measurement System and Carolinas Comfort Scale. We categorized patients with chronic pain if their score on Carolinas Comfort Scale was greater than or equal to 3. Multivariable logistic regression analysis was used to identify predictors of chronic pain. ResultsA total of 960 patients met inclusion criteria. Mean age was 59 (± 14, standard deviation) years, 89 (9.3%) of whom were female. Six percent of patients met criteria for chronic pain (Carolinas Comfort Scale ≥3). On multivariable analysis, predictors for chronic pain were age 45 (P < .001), female sex (P = .006), preoperative pain visual analog scale ≥1 (P = .025), prior inguinal hernia repair (P = .045), higher American Society of Anesthesiologists class (P = .041), use of multifilament polyester mesh (P = .0448), and intraoperative placement of a urinary catheter (P = .009). ConclusionLaparoscopic inguinal hernia repair results in 6.0% of patients experiencing chronic pain. We identified multiple predictors for chronic pain.

211. Complications and outcomes in small vs large surgeries for ASD?

BACKGROUND CONTEXT Traditionally, adult spinal deformity (ASD) has been treated with long segment fusions with the goal of restoring sagittal and coronal alignment. Long segment fusions can be associated with high rates of complications and morbidity. Some patients are reluctant to undergo large procedures. Others have comorbidities excluding them as good surgical candidates for long fusions. PURPOSE To compare baseline and postoperative HRQL and radiographic outcomes and revisions and complications in small vs longer fusions for ASD. STUDY DESIGN/SETTING Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE Surgical ASD patients OUTCOME MEASURES ODI, SF36-PCS, SRS22, NRS back and leg pain. METHODS A prospective database of operative ASD patients who completed two year follow up was analyzed. Prior thoracolumbar fusions were excluded. Patients were divided into short fusions (SF: £3 levels) and long fusions (LF: ³6 levels). LF and SF patients were compared in baseline alignment. Propensity matching (PSM) controlling for baseline alignment (TPA and maximum coronal cobb) was performed to compare SF and LF in HRQL improvement, postop alignment and complications. Subanalysis of SF identified which patients were more likely to have successful surgery. The level of significance was p RESULTS A total of 298 patients met inclusion criteria (SF n=20, mean levels fused 2.13; LF n=275, mean fusion levels 12.33). Prior to PSM, LF had greater PT, coronal cobb, and TPA. Following PSM, LF had better improvements in PILL (20.8 vs 3.37), PT (8.57 vs 0.21), TPA (8.68 vs 2.07), and coronal cobb (17.3 vs 5.33) all p CONCLUSIONS This study shows that a more limited fusion could be an alternative to the more traditional long segment fusion in carefully selected patients with adult spinal deformity since there were fewer complications but similar short-term (2-year) satisfaction rates and HRQL improvements. Patients undergoing long fusions had better improvements in alignment. The majority of sagittal only deformities undergoing short fusions required revision surgery. The durability of short fusions in the setting of ASD needs to be investigated with long term studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

228. A predictive model of perioperative myocardial infarction in spine surgery

BACKGROUND CONTEXT Emphasis has been placed upon reducing perioperative complications in spinal operations, of which cardiac complications remain among the most devastating for patients. Myocardial infarction (MI), along with its predictive factors, has been an understudied complication. PURPOSE To assess the incidence and risk factors for perioperative myocardial infarctions in spine surgery patients. STUDY DESIGN/SETTING Retrospective case control study PATIENT SAMPLE A total of 196,086 surgical spine patients OUTCOME MEASURES Predictors of MI following surgical spine intervention METHODS A patient was categorized as having sustained a postsurgical MI in this study if it occurred intraoperatively or within 30 days of surgery, manifested by documentation of ECG changes accordingly: ST elevation >1mm in two or more contiguous leads, new left bundle branch, new Q-wave in two or more contiguous leads, or new elevation in troponin greater than three times upper level of the reference range. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests, as appropriate. Descriptive statistics, including frequency counts for categorical variables and means and standard deviations, were calculated to summarize demographics and clinical profiles such as spinal diagnoses and comorbidity. Univariate/multivariate analyses were run to assess predictive factors of MI in spine surgery patients. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. RESULTS Of 196,523 patients (57.1±14.2 years, 48% female, 30.4±6.5 kg/m2) undergoing elective spine surgery, 436 patients had an acute MI intraoperatively or within 30 days postoperatively (Spine-MI) (69.07±10.4 years, 42% female, 30.39±6.22 kg/m2). Incidence of MI did not change significantly from 2010 to 2016 (0.2% to 0.3%, p=0.298). Spine-MI patients underwent significantly more fusions than elective spine surgical patients who did not have an MI (73.6% vs 58.4%, p CONCLUSIONS A model with good predictive capacity to predict MI after spine surgery now exists. Predictive modeling of myocardial infarction following spine operations can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical Management of Ulnar Metacarpal Base Fracture-Dislocations: A Systematic Review.

Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small case volumes. Our purpose is to review the surgical techniques, outcomes, and complications of ulnar CMC joint stabilization. A literature search was performed of all articles published on the surgical treatment and outcomes of ulnar CMC fracture dislocations using PubMed and Google Scholar databases between the years 2014 and 2019. Data were pooled and analyzed, assessing surgical techniques and hand outcome measures: union, recurrent dislocations, range of motion, grip strength, and complications. Six studies met inclusion criteria. All surgical patients, regardless of technique, went on to union with no incidents of recurrent instability. Grip strength was significantly decreased postoperatively (82.7% of uninjured side). Patients with CMC dislocations of both the fourth and fifth ray had similar postoperative outcomes to those with CMC dislocations of the fifth ray alone. One third of plate and screw constructs required plate removal, due to breakage (2) or implant-related pain (4). Plate-related symptoms resolved after removal in all cases. Delayed treatment decreased the effectiveness of nonoperative treatment, and increased the likelihood of postoperative pain, chronic deformity, malunion, and CMC osteoarthritis. Closed reduction percutaneous pinning, open reduction percutaneous pinning, and open reduction internal fixation with CMC joint bridging or dorsal buttress plating are all well described, safe techniques with low complication rates. Early, accurate diagnosis of fourth and fifth CMC joint fracture-dislocations is crucial for optimizing hand function and postoperative outcomes.

Short-term quality of life comparison of laparoscopic, open, and robotic incisional hernia repairs.

Outcomes of incisional hernia repair (IHR) include recurrence and quality of life (QOL). Operative approaches include laparoscopic, open, and robotic approaches. Data regarding comparative QOL outcomes among these repair types are unknown. Our study evaluates quality of life after three approaches to IHR. Patients undergoing open (OHR), laparoscopic (LIHR), and robotic extra-peritoneal (RIHR) at a single institution from 2009 to 2019 were reviewed from a prospectively managed quality database. Short-term QOL was compared among the three procedures using the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS), objective pain scores and postoperative narcotic use. Data regarding length of stay (LOS), emergency department (ED) visits, readmission, reoperations and surgical site infection (SSI) were also collected. A total of 795 patients undergoing IHR were analyzed (418 open, 300 laparoscopic and 77 robotic). Patient were similar in age, gender and co-morbidities. LIHR patients had higher BMI and RIHR patients had larger hernia and mesh size. LOS was longer and rate of SSI was higher for OIHR compared to laparoscopic and RIHR. Patients undergoing LIHR reported increased narcotic use, Visual Analogue Scale (VAS) and CCS pain scores compared to open and robotic repair. Return to daily activity was 4days shorter for robotic than open and laparoscopic repair; ED visits, readmissions, reoperations, and other QOL domains were similar. Our data suggests that short-term quality of life after robotic extra-peritoneal IHR is improved compared to open and laparoscopic repair. Additional follow up is required to determine differences in long-term QOL after IHR.

P104: Therapeutic mammoplasty (TM) for large or multifocal tumours: Rate of clear surgical margins and long-term oncological outcomes

Introduction: Original studies evaluating oncological safety of breast conserving surgery excluded large or multi-focal breast cancers and variations in surgical technique, study design and outcome measures make interpretation of data regarding this challenging. TM achieves acceptable aesthetic outcomes for tumours, whilst avoiding need for mastectomy. We assess the ability for TM to achieve clear surgical margins (CSM), its local recurrence rate, disease-free and overall survival, over a 14-year follow-up period.

Laparoscopic repair of recurrent inguinal hernia offers similar outcomes and quality of life to primary laparoscopic repair.

Open repair of recurrent inguinal hernias has been shown to result in significantly poorer perioperative outcomes when compared to open primary hernia repair. However, limited data exist comparing primary and recurrent laparoscopic inguinal hernia repair (LIHR). The aim of our study was to compare quality of life and clinical outcomes between these two groups. Patients undergoing LIHR at a single institution from 2012 to 2018 were reviewed from a prospectively managed quality database. Quality of life outcomes were measured using the surgical outcomes measurement system and Carolinas Comfort Scale surveys administered preoperatively and at 3weeks, 6months, 1year, and 2years postoperatively. A total of 1298 patients undergoing LIHR were analyzed (1139 primary, 159 recurrent). There were older and more male patients in the recurrent group. There were no major complications, and recurrence rates were not significantly different between primary and recurrent groups (1.3% vs 2.4% p = 0.56), while hematoma occurred more commonly in the recurrent group (1.5% vs 4.4% p = 0.0205). Short- and long-term quality of life were similar between the groups except lower (worse) physical function at 3weeks (32.9 ± 4.2 vs 31.9 ± 4.4: p = 0.0186) and 6months (34.6 ± 2.8 vs 33.8 ± 3.0: p = 0.0175) and increased sensation of mesh (3weeks) in the recurrent group (2.3 ± 5.4 vs 3.3 ± 5.3: p = 0.0160). Recurrent inguinal hernia repair using laparoscopic totally extraperitoneal approach is as safe and effective as primary repair with similar quality of life.

Health-Related Quality of Life in Craniofacial Conditions: Concordance Between Child and Parent Reports.

Craniofacial conditions (CFCs) profoundly influence health-related quality of life (HRQoL). In children with CFCs, patient-reported outcome measures have become an integral adjunct to more objective surgical outcome measures. Patient-reported outcome measures are designed to assess HRQoL domains. Few studies have evaluated parent and child agreement about HRQoL in the context of CFCs. The aims of this study were to explore the impact of CFCs on HRQoL domains in children and their parents and to determine whether patient and parent perspectives converge. The Craniofacial Conditions Quality of Life Scale (CFC-QoL) is a newly developed 5-domain survey available in child self-report and parent report and in English- and Spanish-language versions. The 5 domains are the following: social impact, psychological function, physical function, family impact, and appearance impact. Children with CFCs (ages 7-21 years) and parents of children with CFCs were recruited via the craniofacial care team clinic at a major metropolitan children's hospital. All children and parents completed the CFC-QoL Scale in their preferred language of English or Spanish. Scale internal consistencies were calculated for child patients and parents, for English and Spanish versions. Scores on the 5 domains were compared for children and parents across English versus Spanish versions. For children with CFCs (N = 75), the sex was distributed almost equally. Patients were mostly Hispanic (69.3%), and their ages ranged from 7 to 21 years old (M = 13.2, SD = 3.62). The mean values for patient and parent scores were low, suggesting good HRQoL across all 5 domains. Pearson correlation coefficients were computed to explore the interrelationships between patient and parent report for each of the 5 CFC-QoL subscales. For the total sample, patient and parent scores were significantly and moderately positively correlated for all subscales. When analyzed separately based on sex, ethnicity, and diagnostic group, the correlation patterns were not identical to those found for the total sample. When analyzed separately for diagnostic group, there was less consistency in patterns, with patient-parent dyads showing different levels of agreement based on child's diagnostic grouping. Although there is substantial agreement between parents and patients when considered on a group level, there is moderate agreement between patients and parents when considered at the dyadic level, underscoring the importance of measuring and considering both perspectives.

Surgical learning curve for robotic multiplex partial nephrectomy: The National Cancer Institute Experience.

660 Background: Multiplex partial nephrectomy (MPN) remains the standard of care for hereditary and bilateral kidney tumors. Our institution is an international referral center for the management of hereditary renal cell carcinoma, and therefore has considerable experience with MPN. The objective of this study was to evaluate surgical learning curve for MPN among multiple surgeons at a single institution over an 11-year period. Methods: Retrospective review of a prospectively maintained registry of patients who underwent MPN from 2007-present. The first 100 consecutive surgeries of 3 NIH fellowship trained Urologic Oncologists were identified and evaluated in quartiles. Surgical outcome measures including operative duration (OD), estimated blood loss (EBL), number of tumors resected, and complication rate were chosen as surrogate markers of learning curve. Differences in individual surgeon outcomes were evaluated and variables including re-do surgery and surgical approach were considered. Significant differences found among quartiles or among surgeon were evaluated with multivariate logistic regression analysis. Results: A total of 300 MPN's were identified. In the quartile analysis, there were no significant differences in OD, EBL, numbers of tumors resected or rates of complication. Among surgeon factors, there were differences in surgical approach and EBL (table). In a multivariate analysis of factors associated with EBL, open approach (95%CI 245-831), p &lt; 0.0001) and number of tumors (95%CI 43-82), p &lt; 0.0001) were independently associated. No factors were associated increased rate of complication. Conclusions: As surgeons progressed through their first 100 operations, no true learning curve was appreciated, with similar outcomes in each quartile. Among surgeon factors, open surgical approach appears to drive difference in EBL.[Table: see text]

Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, −0.2; 95% confidence interval, −5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Surgical Outcome of Levator Resection in Congenital Ptosis with Poor Levator Function at a Tertiary Care Centre

Introduction: Treatment of congenital ptosis is challenging as results are unpredictable. The ideal surgical technique which gives optimal cosmetic outcome without complications is still evolving. Tarso-frontalis sling operation is the preferred standard of care when levator action is poor but it has high rate of complications. Hence, supramaximal levator resection has been advocated over the past two decades as an alternative treatment modality. Aim: To assess the effectiveness of supramaximal levator resection in patients with unilateral simple congenital ptosis, having poor levator action (≤4 mm). Materials and Methods: A longitudinal interventional study was conducted over a period of six months. Fifteen patients, during the study period, underwent supramaximal levator resection under General Anesthesia (GA) after taking informed consent from next of kin. All patients were evaluated on day one, one week, one, three and six months after surgery. Surgical outcome measures were change in margin reflex distance-1, vertical palpebral fissure height and inter-eyelid difference of margin reflex distance. Success was defined as margin reflex distance-1 (MRD-1) ≥3 mm and inter-eyelid difference of MRD-1 between 0.5 and 1 mm. Results: There were 10 females (60%) and 5 males (40%) in the study group. The mean age group at the time of ptosis surgery was 5.73±0.55 years (range from 03 and 11 years). A good surgical outcome was obtained in 12 (80%) patients. In 02 (13.3%) patients under-correction was noted which did not need further intervention as visual axis was clear. Upper lid swelling occurred in one patient (6.6%) which was treated with anti-inflammatory medications. Conclusion: Supramaximal levator resection may be considered in all cases of unilateral ptosis patients with poor levator action as this procedure yields good surgical outcomes.

More than just morbidity and mortality - quality of recovery and long-term functional recovery after surgery.

Traditional surgical outcome measures include minor and major complications, hospital length of stay and sometimes longer-term survival. Each of these is important but there needs to be greater emphasis on patient-reported outcome measures. Global measures of a patient's quality of recovery, avoidance of postoperative morbidities, early hospital discharge to home (without re-admission) and longer term disability-free survival can better define postoperative recovery. A patient's recovery pathway can be mapped through the immediate days or weeks after surgery with documentation of morbidity using the postoperative morbidity survey and/or a quality of recovery score, days alive and at home up to 30days after surgery and then longer term disability-free survival using the WHO Disability Assessment Schedule 2.0 scale. These can be used to define quality of recovery after surgery.