Surgical Perspective Research Articles

Just another tool in their repertoire: uncovering insights into public and patient perspectives on clinicians' use of machine learning in perioperative care.

Successful implementation of machine learning-augmented clinical decision support systems (ML-CDSS) in perioperative care requires the prioritization of patient-centric approaches to ensure alignment with societal expectations. We assessed general public and surgical patient attitudes and perspectives on ML-CDSS use in perioperative care. A sequential explanatory study was conducted. Stage 1 collected public opinions through a survey. Stage 2 ascertained surgical patients' experiences and attitudes via focus groups and interviews. For Stage 1, a total of 281 respondents' (140 males [49.8%]) data were considered. Among participants without ML awareness, males were almost three times more likely than females to report more acceptance (OR = 2.97; 95% CI, 1.36-6.49) and embrace (OR = 2.74; 95% CI, 1.23-6.09) of ML-CDSS use by perioperative teams. Males were almost twice as likely as females to report more acceptance across all perioperative phases with ORs ranging from 1.71 to 2.07. In Stage 2, insights from 10 surgical patients revealed unanimous agreement that ML-CDSS should primarily serve a supportive function. The pre- and post-operative phases were identified explicitly as forums where ML-CDSS can enhance care delivery. Patients requested for education on ML-CDSS's role in their care to be disseminated by surgeons across multiple platforms. The general public and surgical patients are receptive to ML-CDSS use throughout their perioperative care provided its role is auxiliary to perioperative teams. However, the integration of ML-CDSS into perioperative workflows presents unique challenges for healthcare settings. Insights from this study can inform strategies to support large-scale implementation and adoption of ML-CDSS by patients in all perioperative phases. Key strategies to promote the feasibility and acceptability of ML-CDSS include clinician-led discussions about ML-CDSS's role in perioperative care, established metrics to evaluate the clinical utility of ML-CDSS, and patient education.

[Translated article] Management of spinal deformities caused by osteoporotic vertebral fractures

Osteoporosis and fragility play a significant role in the treatment and planning of patients with deformity secondary to osteoporotic vertebral fracture (OVF). The resulting deformity can present significant challenges for its management, both from a medical and surgical perspective. The need for a specific classification for these deformities, including the potential for the development of artificial intelligence and machine learning in predictive analysis, is emerging as a key point in the coming years. Relevant aspects in preoperative optimisation and management of these patients are addressed. A classification with therapeutic guidance for the management of spinal deformity secondary to OVF is developed, emphasising the importance of personalised treatment. Flexibility and sagittal balance are considered key aspects. On the other hand, we recommend, especially with these fragile patients, management with minimally invasive techniques to promote rapid recovery and reduce the number of complications.

Microsurgical anatomy and the inner architecture of the retrocommissural portion of the hippocampal formation demonstrated through fiber microdissection.

An understanding of the complex nomenclature and 3D spatial relations between the cortical and white matter components of the retrocommissural portion of the hippocampal formation is essential for a successful outcome when performing surgery in the mediobasal temporal region. The goal of this study was to clarify the nomenclature related to the retrocommissural portion of the hippocampal formation and to provide a detailed description of its topography and inner structure from a relevant surgical perspective. This description can serve as an anatomical reference for approaching lesions in the mediobasal temporal region. Fiber microdissection was performed from the superolateral and inferior aspects on 20 previously frozen, formalin-fixed human brains. Three formalin-fixed plastinated brain specimens were then sectioned in the coronal, axial, and sagittal planes, and the relevant sections were studied. Based on its relationship with the corpus callosum, the hippocampal formation is subdivided into precommissural, supracommissural, and retrocommissural sections. The retrocommissural portion of the hippocampal formation, a structure in the mediobasal temporal region, is a component of both the floor of the temporal horn and the medial surface of the cerebral hemisphere. It includes the hippocampus (Ammon's horn and the dentate gyrus), subiculum, and related white matter fibers. Step-by-step microdissection revealed the complex ventricular and cisternal relationships of the retrocommissural portion of the hippocampal formation in the mediobasal temporal region. This further allowed clear distinction of each component of this formation in order to understand their complex reciprocal relationships that comprise a unique internal architecture and external morphology. The fiber microdissection technique provides a valuable perspective for understanding the complex structure and relations of the components of the retrocommissural portion of the hippocampal formation. This study clarifies and supplements the information presently available in the literature by offering an anatomical reference essential for differentiating the topographic diagnosis and safer surgical planning for any lesion within this formation or the mediobasal temporal region.

Modern surgical strategies in pediatric neuroblastoma: Evolving approaches and treatment principles.

Neuroblastoma, the most common extracranial solid tumor in children under the age of 5, has been described as early as the 19th century, and its complexity has continued to intrigue researchers, as well as medical and surgical specialists. At one end of the phenotypic spectrum, neuroblastoma is self-limiting with minimal to no intervention required, while on the opposite end exists the challenge of refractory disease despite aggressive management and toxic systemic treatments. The goal of this review is to describe a comprehensive surgical perspective and contemporary approach to neuroblastoma.

Redo Thyroidectomy: Updated Insights.

The risk of post-operatory hypothyroidism and hypocalcaemia, along with recurrent laryngeal nerve injury, is lower following a less-than-total thyroidectomy; however, a previously unsuspected carcinoma or a disease progression might be detected after initial surgery, hence indicating re-intervention as mandatory (so-called "redo" surgery) with completion. This decision takes into consideration a multidisciplinary approach, but the surgical technique and the actual approach is entirely based on the skills and availability of the surgical team according to the standard protocols regarding a personalised decision. We aimed to introduce a review of the most recently published data, with respect to redo thyroid surgery. For the basis of the discussion, a novel vignette on point was introduced. This was a narrative review. We searched English-language papers according to the key search terms in different combinations such as "redo" and "thyroid", alternatively "thyroidectomy" and "thyroid surgery", across the PubMed database. Inclusion criteria were original articles. The timeframe of publication was between 1 January 2020 and 20 July 2024. Exclusion criteria were non-English papers, reviews, non-human studies, case reports or case series, exclusive data on parathyroid surgery, and cell line experiments. We identified ten studies across the five-year most recent window of PubMed searches that showed a heterogeneous spectrum of complications and applications of different surgeries with respect to redo interventions during thyroid removal (e.g., recurrent laryngeal nerve monitoring during surgery, other types of incision than cervicotomy, the use of parathyroid fluorescence, bleeding risk, etc.). Most studies addressing novel surgical perspectives focused on robotic-assisted re-intervention, and an expansion of this kind of studies is expected. Further studies and multifactorial models of assessment and risk prediction are necessary to decide, assess, and recommend redo interventions and the most adequate surgical techniques.

The oculomotor cistern and pituitary adenomas: anatomical and clinical study.

The oculomotor cistern (OMC) is a meningeal cuff filled with CSF that contains the oculomotor nerve (cranial nerve [CN] III) at the level of the lateral wall of the cavernous sinus. Only a few studies have investigated the involvement of the OMC by pituitary adenomas (pituitary neuroendocrine tumors [PitNETs]), mainly with relatively small case series. The aim of this study was to perform a histomorphological description of the OMC and systematically analyze its involvement by PitNETs from radiological, clinical, and surgical perspectives. Ten hemisellae from formalin-fixed specimens were studied with 3-µm sections. Digital image analysis software was used for morphological and quantitative assessments. Clinical, radiological, surgical, and histological data of patients undergoing endoscopic transsphenoidal surgery for PitNETs at the University of Brescia, Italy, between 2014 and 2021 were recorded. OMC involvement was graded as not compressed, compressed, and invaded. The same surgical team operated on all patients. The OMC had an elliptical shape with an average area of 3.1 mm2 and a length of 5.5 mm. No cisternal points of weakness were recognized in the histomorphological study. Of 315 patients, 246 had complete data: apoplexy and CN III palsy were documented in 6.9% and 8.5%, respectively. OMC compression and invasion were recorded in 106 (43.1%) and 23 (9.3%) patients. Significant associations between OMC involvement and PitNET dimensions (p < 0.001), Knosp grade (p < 0.001), preoperative oculomotor palsy (p < 0.001), Ki-67 percentage (p = 0.009), and recurrence/progression of residual tumor (p = 0.008) were found. A new postoperative CN III palsy was evident in 2%: transient in 4 cases, and persistent in 1 patient treated for a recurrent PitNET who experienced a local infection complication. Preoperative CN III palsy improved in 10 cases. Significant OMC involvement by PitNETs might be underrecognized, but it can be treated using the endoscopic transsphenoidal approach, and it affects patient outcomes.

Manejo de la deformidad espinal en el contexto de fracturas por compresión vertebral osteoporóticas

Osteoporosis and fragility play a significant role in the treatment and planning of patients with deformity secondary to osteoporotic vertebral fracture (OVF). The resulting deformity can present significant challenges for its management, both from a medical and surgical perspective. The need for a specific classification for these deformities, including the potential for the development of artificial intelligence and machine learning in predictive analysis, is emerging as a key point in the coming years. Relevant aspects in preoperative optimization and management of these patients are addressed. A classification with therapeutic guidance for the management of spinal deformity secondary to OVF is developed, emphasizing the importance of personalized treatment. Flexibility and sagittal balance are considered key aspects. On the other hand, we recommend, especially with these fragile patients, management with minimally invasive techniques to promote rapid recovery and reduce the number of complications.

Robotic-assisted Lymphovenous Anastomosis of the Central Lymphatic System.

Recent advances in robotic microsurgery have enabled the application of robotic technology in central lymphatic reconstruction. Although the use of microsurgical robots demands careful consideration of associated costs and potentially prolonged operating times, it may offer improved surgical approaches and enhanced accessibility to deeper anatomical structures such as the thoracic duct (TD). We report on successful reconstruction of the central lymphatic system using the Symani Surgical System in four patients with lesions of the central lymphatic system. The patients were of different age (range: 8 mo-60 y) and had variable conditions, including central conducting lymphatic anomaly and other rare anomalies of the central lymphatic pathways. Depending on the underlying pathology, a cervical access (n = 1) or median laparotomy (n = 3) was chosen to access the TD and perform anastomosis with a nearby vein. In all patients, anastomoses were patent, and chyle leakage decreased postoperatively. From a surgical perspective, the Symani Surgical System improved the precision of the microsurgeon and accessibility to the deep-lying TD. Considering the high morbidity and rarity of pathologies of the central lymphatic system, robotic-assisted microsurgery holds substantial promise in expanding and improving the microsurgical treatment for central lymphatic anomalies.

Recommendations of the Blue Ribbon Committee II for the Optimization of Surgical Education and Training in the United States: The Surgical Trainee Perspective.

This study aims to appraise recommendations from an expert panel of surgical educators on optimizing surgical education and training in the setting of contemporary challenges. The Blue Ribbon Committee (BRC II), a group of surgical educators, was convened to make recommendations to optimize surgical training considering the current changes in the landscape of surgical education. Surgical trainees were recruited to assess their impressions of the recommendations. A mixed-methods study design was employed, with a survey, followed by focus group interviews. Participating residents and fellows were recruited through a purposeful sampling approach. Descriptive statistics were applied to analyze the survey data, and a thematic data analysis on interview transcripts was employed. The majority of trainee respondents (n=16) thought that all of the subcommittee recommendations should be included in the final BRC II recommendations and paper. According to the interviews, overall, the feedback from the trainees was positive, with particular excitement around work-life integration, education support and faculty development, and funding pitfalls. Some themes about concerns included a lack of clarity about the recommendations, concern about some recommendations being in conflict with one another, and a disconnect between the initial BRC II survey and the subsequent recommendations. The residents gathered for this focus group were encouraged by the thought, effort, and intention that gathered the surgical leaders across the country to make the recommendations. While there were areas the trainees wanted clarity on, the overall opinion was in agreement with the recommendations.

Analysis of surgical oncology-educator perspectives for the development of a contemporary curriculum for the outpatient learning environment

PurposeThe purpose of this study was to perform a targeted needs assessment of surgical oncology stakeholders engaged in surgical education of students and trainees. The aim was to determine the appropriate elements of a formal curriculum to be administered to students and residents rotating in the outpatient surgical oncology setting.MethodsA 10-min survey was sent to surgical oncologists around the country that are a part of the Society of Surgical Oncology (SSO). Data obtained from this survey were analyzed to distinctly identify limitations to education in Surgical Oncology and will allow us to determine which educational goals to prioritize in a curriculum.Results189 responses to the needs assessment were received (7% response rate). Most surgeons were in academic practice (77%) and felt that trainees were not fully prepared for an outpatient clinic (57%) and did endorse the need for a curriculum (74%). Barriers identified to teaching and learning included time, abbreviated contact with learners and the volume of patients. Higher yield topics to be included in a future curriculum were identified. More than half of respondents felt that a curriculum could improve feedback, NBME Surgery Subject Exam scores, resident ABSITE scores and patient comfort.ConclusionsThis study represents a novel effort in assessing the unique needs of surgical oncologists within the outpatient learning environment. Building upon the insights gleaned from our survey, the next phase will entail conducting focus groups with respondents to delve deeper into the intricacies of designing an outpatient surgical oncology clinical curriculum tailored for medical students and junior residents. By fostering collaborative discussions among stakeholders, we aim to refine curriculum components in an iterative process and address identified gaps in educational resources and ultimately improve the quality of patient care in the outpatient setting.

Frontal trans opercular approaches to the insula: building the mental picture from procedure-guided anatomical dissection.

Performing transopercular frontal approaches to the insula, widely used in glioma surgeries, necessitates a meticulous understanding of both cortical and subcortical neuroanatomy. This precision is vital for preserving essential structures and accurately interpreting the results of direct electrical stimulation. Nevertheless, acquiring a compelling mental image of the anatomy of this region can be challenging due to several factors, among which stand out its complexity and the fact that white matter fasciculi are imperceptible to the naked eye in the living brain. In an effort to optimize the study of the anatomy relevant to this topic, we performed a procedure-guided laboratory study using subpial dissection, fiber dissection, vascular coloration, and stereoscopic photography in a "real-life" surgical perspective. Nine cerebral specimens obtained from body donation were extracted and fixed in formalin. Colored silicone injection and a variant of Klinglers's technique were used to demonstrate vascular and white matter structures, respectively. We dissected and photographed the specimens in a supero-antero-lateral view to reproduce the surgeon's viewpoint. The anatomy related to the development of the surgical corridor and resection cavity was documented using both standard photography and the red-cyan anaglyph technique. The anatomy of frontal transopercular approaches to the insula involved elements of different natures-leptomeningeal, cortical, vascular, and fascicular-combining in the surgical field in a complex disposition. The disposition of these structures was successfully demonstrated through the aforementioned anatomical techniques. Among the main structures in or around the surgical corridor, the orbital, triangular, and opercular portions of the inferior frontal gyrus are critical landmarks in the cortical stage, as well as the leptomeninges of the Sylvian fissure and the M2-M4 branches of the middle cerebral artery in the subpial dissection stage, and the inferior fronto-occipital, uncinate and arcuate fasciculi, and the corona radiata in establishing the deep limits of resection. Procedure-guided study of cerebral hemispheres associating subpial, vascular, and fiber dissection from a surgical standpoint is a powerful tool for the realistic study of the surgical anatomy relevant to frontal transopercular approaches to the insula.

Predicting Nerve Course Variations to Prevent Iatrogenic Lesions: A Surgical Perspective on Sural Nerve Variations.

There are several documented variations of the sural nerve noted within the literature. This cadaveric study was conducted to provide a surgical perspective to either directly addressing the sural nerve, or avoiding it depending on the injury or pathology being surgically addressed. Twenty-five preserved cadaveric limbs were dissected from the popliteal fossa to the foot. Three locations of the course of the sural nerve data were analyzed. The first location (M1) was from the head of the fibula to the sural nerve. The second location (M3) was from 2.54 cm proximal to the distal tip of the lateral malleolus to the sural nerve. The third location (M2) was from the shaft of the fibula at the halfway point between measurements 1 and 2 to the course of the sural nerve. The types of variations were noted as well, compared to previous studies, highlighting the abundance of sural nerve variations in the lower limb that clinicians and surgeons need to be aware of and ready to address. The sural nerve courses 4.6 cm posterior from the fibula at the proximal fibula and mid fibula and 4.5 cm at the distal fibula. The 25 sural nerve variations are not reflective of what has been previously published in the literature. The data can be utilized in preoperative planning in addressing or avoiding the sural nerve involving the posterior superficial compartment of the leg.

Reproductive Planning and Infertility: Training the Next Generation of Surgeons

Female surgeons face increased rates of fertility challenges compared to the general population. We aim to understand surgical trainees' understanding and perspectives on family planning. A 35-question survey was emailed to program directors at all US surgical residency programs for distribution to residents. Descriptive analyses were performed to evaluate resident understanding and perspectives on family planning and fertility treatments. A total of 121 residents responded to the survey. Most were female (n​=​78; 65​%). Responders indicated the need to postpone pregnancy during training (female: n​=​48, 64​% vs male n​=​18, 45​%; p​=​0.09). Potential negative career consequences (n​=​50; 42​%), limited leave benefits (n​=​47; 39​%), and lack of childcare (n​=​45; 38​%) were primary reasons for postponing pregnancy. Only nine responders (8​%) received fertility-preservation education. Surgical trainees delay pregnancy for career and social support concerns and are interested in reproductive preservation. Fertility education could provide needed support for trainees.

Wilms Tumor with Vena Caval Intravascular Extension: A Surgical Perspective.

Wilms tumor (WT) is the most common kidney tumor in pediatric patients. Intravascular extension of WT above the level of the renal veins is a rare manifestation that complicates surgical management. Patients with intravascular extension are frequently asymptomatic at diagnosis, and tumor thrombus extension is usually diagnosed by imaging. Neoadjuvant chemotherapy is indicated for thrombus extension above the level of the hepatic veins and often leads to thrombus regression, obviating the need for cardiopulmonary bypass in cases of cardiac thrombus at diagnosis. In cases of tumor extension to the retrohepatic cava, neoadjuvant therapy is not strictly indicated, but it may facilitate the regression of tumor thrombi, making resection safer. Hepatic vascular isolation and cardiopulmonary bypass increase the risk of bleeding and other complications when utilized for tumor thrombectomy. Fortunately, WT patients with vena caval with or with intracardiac extension have similar overall and event-free survival when compared to patients with WT without intravascular extension when thrombectomy is successfully performed. Still, patients with metastatic disease at presentation or unfavorable histology suffer relatively poor outcomes. Dedicated pediatric surgical oncology and pediatric cardiothoracic surgery teams, in conjunction with multimodal therapy directed by a multidisciplinary team, are preferred for optimized outcomes in this patient population.

Current surgical practice for central venous access to deliver chemotherapy and enteral access for nutritional support in pediatric patients with an oncological diagnosis.

Central venous access through tunneled central venous catheters (CVCs) are one of the cornerstones of modern oncologic practice in pediatric patients since CVCs provide a reliable access route for the administration of chemotherapy. Establishing best practices for CVC management in children with cancer is essential to optimize care. This article reviews current best practices, including types of devices, their placement, complications, and long-term outcomes. Additionally, nutrition status and nutritional support are also very important determinants of outcomes and care in pediatric surgical oncology patients. We review current nutritional assessment, support, access for enteral and parenteral nutrition delivery, and their complications, mainly from a surgical perspective. Overall, access surgery, whether for CVCs, or for enteral access can be challenging, and best practice guidelines supported by current though limited evidence are necessary to minimize complications and optimize outcomes.

The Role of the Intestinal Flora and Its Derivatives in Neurocognitive Disorders: A Narrative Review from Surgical Perspective.

Perioperative neurocognitive dysfunction is a significant concern for population health, impacting postoperative recovery and increasing the financial burden on patients. With an increasing number of surgical procedures being performed, the prevention and management of perioperative neurocognitive dysfunction have garnered significant attention. While factors such as age, lifestyle, genetics, and education are known to influence the development of cognitive dysfunction, recent research has highlighted the role of the gut microbiota in neurological health. An increased abundance of pro-inflammatory gut microbiota can trigger and worsen neuroinflammation, neuronal cell damage, and impaired cellular autophagy. Moreover, the inflammation-promoting gut microbiota can disrupt immune function, impair neuroautophagy, and affect the production and circulation of extracellular vesicles and neurotransmitters. These factors collectively play a role in the onset and advancement of cognitive impairment. This narrative review delves into the molecular mechanisms through which gut microbiota and their derivatives contribute to cognitive impairment, focusing on the impact of anesthesia surgery, changes in gut microbial populations, and perioperative cognitive impairment associations. The study suggests that alterations in the abundance of various bacterial species and their metabolites pre- and post-surgery may be linked to postoperative cognitive impairment. Furthermore, the potential of probiotics or prebiotics in addressing cognitive impairment is discussed, offering a promising avenue for investigating the treatment of perioperative neurocognitive disorders.

A Synopsis of Biomarkers in Glioblastoma: Past and Present.

Accounting for 48% of malignant brain tumors in adults, glioblastoma has been of great interest in the last decades, especially in the biomolecular and neurosurgical fields, due to its incurable nature and notable neurological morbidity. The major advancements in neurosurgical technologies have positively influenced the extent of safe tumoral resection, while the latest progress in the biomolecular field of GBM has uncovered new potential therapeutical targets. Although GBM currently has no curative therapy, recent progress has been made in the management of this disease, both from surgical and molecular perspectives. The main current therapeutic approach is multimodal and consists of neurosurgical intervention, radiotherapy, and chemotherapy, mostly with temozolomide. Although most patients will develop treatment resistance and tumor recurrence after surgical removal, biomolecular advancements regarding GBM have contributed to a better understanding of this pathology and its therapeutic management. Over the past few decades, specific biomarkers have been discovered that have helped predict prognosis and treatment responses and contributed to improvements in survival rates.

Subacromial balloon spacer massive rotator cuff tear treatment systematic review and meta-analysis: Patient selection and physical therapy may be keys to outcome success.

Subacromial balloon spacer implantation (SBSI) efficacy for massive rotator cuff tear treatment was evaluated based on perceived shoulder function, active shoulder mobility, pain, complications and research study methodological quality. The purpose was to better discern the efficacy of this device from both surgical and rehabilitative perspectives to improve patient outcomes. PubMed, EMBASE and Cochrane Library databases were searched (1 January 2010 to 1 June 2024) using 'balloon spacer', 'subacromial spacer', 'subacromial balloon spacer', 'shoulder spacer' and 'inspace' terms. Pre-surgery (baseline), 12-month (12-m) and 24-month (24-m) post-SBSI mean changes were compared using one-way ANOVA and Scheffe post hoc tests, and comparative study effect sizes were calculated (p ≤ 0.05). This review consists of 27 studies with 894 patients (67.8 ± 5 years of age) and 29.4 ± 17-month follow-up. Modified Coleman Methodology Scores (MCMS) revealed fair overall quality (mean = 61.4 ± 11). Constant-Murley scores improved from 34.8 ± 6 (baseline), to 64.2 ± 9 (12-m) and 67.9 ± 8 (24-m) (12-m, 24-m > baseline, p < 0.001). ASES scores improved from 35.1 ± 14 (baseline), to 83.3 ± 7 (12-m) and 81.8 ± 5 (24-m)(12-m, 24-m > baseline, p < 0.001). VAS pain scores improved from 6.6 ± 1 (baseline), to 2.6 ± 1 (12-m) and 2.0 ± 1 (24-m) (12-m, 24-m < baseline, p < 0.001). Flexion increased from 108.5 ± 25° (baseline), to 128.5 ± 30° (12-m) and 151.2 ± 14° (24-m) (24-m > 12-m, baseline, p = 0.01). Abduction increased from 97.7 ± 24° (baseline) to 116.3 ± 23° (12-m) and 142.3 ± 15° (24-m) (24-m > 12-m, baseline, p = 0.02). External rotation (ER) in adduction changed from 33.1 ± 7° (baseline) to 32.5 ± 4° (12-m) and 53.9 ± 9° (24-m)(24-m > 12-m, baseline, p = 0.01). ER at 90° abduction increased from 56.3 ± 3° (baseline) to 83.5 ± 5° (12-m) and 77.1 ± 4° (24-m) (24-m, 12-m > baseline, p = 0.01). Comparison studies, however, displayed insignificant results with small effect sizes. Despite overall fair MCMS scores, at 24-m post-SBSI, shoulder function improved and pain decreased. More rigorous comparative studies, however, revealed insignificant findings. Patients with the potential to re-establish the essential glenohumeral joint force couple that depresses the humeral head on the glenoid fossa and who comply with physical therapy may be more likely to achieve success following SBSI. Level IV.

Are We Supporting Surgical Quality Improvement in Training and Beyond? A Qualitative Study of Surgical Trainees and Practicing Surgeons.

We conducted a qualitative study to describe surgeon and surgical trainee perspectives of quality improvement (QI) in training and practice to elucidate how surgeons and trainees interact with barriers and leverage facilitators to learn and conduct QI. Surgeons and surgical trainees of the American College of Surgeons were recruited via email and snowball sampling to participate in focus groups. Eligible individuals were English speaking surgical trainees or practicing surgeons. We developed a semi-structured focus group protocol to explore barriers and facilitators of quality training and improvement. An inductive thematic approach was used to identify actionable items. Thirty-two surgical trainees and surgeons participated in six focus groups. 28% of participants were trainees (8 residents, 1 fellow) and 72% were practicing surgeons, representing practice settings in university, community, and Veterans Affairs hospitals in urban and suburban regions. Thematic analysis revealed the central theme among trainees was that they lacked necessary support to effectively learn and conduct QI. Dominant sub-themes included lack of formal education, insufficient time, inconsistent mentorship, and maximizing self-sufficiency to promotes success. The central theme among surgeons was that effective QI initiatives require adequate resources and institutional support; however, surgeons in this study were ultimately constrained by institutional limitations. Sub-themes included difficulties in data acquisition and interpretation, financial limitations, workforce and staffing challenges, misaligned stakeholder priorities, and institutional culture. This qualitative evaluation further details gaps in QI demonstrated by previous quantitative studies. There is an opportunity to address these gaps with dedicated QI training and mentorship for surgical trainees and by creating a supportive environment with ample resources for surgeons.

Anatomy of the Buccal Space: Surgical and Radiological Perspectives.

Among the anatomical spaces in the head and neck area, the buccal space has often been studied in dental/oral surgery and cosmetic surgery because it contains the facial vessels, mandibular and facial nerves, and adipose tissue called the buccal fat pad. In addition, as the space can communicate with other spaces, it can be significant in infections. Although the anatomy of the buccal space has been reported in several studies, there have been discrepancies concerning its boundaries, and its communications have often been overlooked. The aim of this review is to examine the anatomy of buccal space including its boundaries, contents, continuity with adjacent spaces, and clinical significance. A literature review was performed on Google Scholar and PubMed. The literature has depicted the anterior, medial, and lateral boundaries more or less consistently, but descriptions of the posterior, superior, and inferior borders are controversial. The buccal space includes the facial arteries, veins, facial nerves, parotid duct, and lymph nodes, which can be described differently depending on definitions and the extent of the space. As it communicates with other anatomical spaces including the masticatory space, it can be a reservoir and a channel for infections and tumors. Buccal fat pads have various clinical applications, from a candidate for flap reconstruction to a target for removal for cosmetic purposes. This review will help understand the anatomy of the buccal space including its boundaries, residing structures, and communication with other spaces from surgical and radiological perspectives.