Years Of Surgical Practice Research Articles

A Polysomnographic Study of Effects of Sleep Deprivation on Novice and Senior Surgeons during Simulated Vitreoretinal Surgery

To assess the impact of a 3-hour polysomnography (PSG)-recorded night of sleep deprivation on next-morning simulated microsurgical skills among vitreoretinal (VR) surgeons with different levels of surgical experience and associate the sleep parameters obtained by PSG with Eyesi-generated performance. Self-controlled cohort study. Eleven junior VR surgery fellows with < 2 years of surgical experience and 11 senior surgeons with > 10 years of surgical practice. Surgical performance was assessed at 7am after a 3-hour sleep-deprived night using the Eyesi simulator and compared with each subject's baseline performance. Changes in Eyesi-generated score (0-700, worst to best), time for task completion (minutes), tremor-specific score (0-100, worst to best), and out-of-tolerance tremor percentage. Polysomnography was recorded during sleep deprivation. Novice surgeons had worse simulated surgical performance after sleep deprivation compared with self-controlled baseline dexterity in the total score (559.1 ± 39.3 vs. 593.8 ± 31.7; P= 0.041), time for task completion (13.59 ± 3.87 minutes vs. 10.96 ± 1.95 minutes; P= 0.027), tremor-specific score (53.8 ± 19.7 vs. 70.0 ± 15.3; P= 0.031), and out-of-tolerance tremor (37.7% ± 11.9% vs. 28.0% ± 9.2%; P= 0.031), whereas no performance differences were detected in those parameters among the senior surgeons before and after sleep deprivation (P ≥ 0.05). Time for task completion increased by 26% (P= 0.048) in the post-sleep deprivation simulation sessions for all participants with a high apnea-hypopnea index (AHI) and by 37% (P= 0.008) among surgeons with fragmented sleep compared with those with normal AHI and < 10 arousals per hour, respectively. Fragmented sleep was the only polysomnographic parameter associated with a worse Eyesi-generated score, with a 10% (P= 0.005) decrease the following morning. This study detected impaired simulated surgical dexterity among novice surgeons after acute sleep deprivation, whereas senior surgeons maintained their surgical performance, suggesting that the impact of poor sleep quality on surgical skills is offset by increased experience. When considering the 2 study groups together, sleep fragmentation and AHI were associated with jeopardized surgical performance after sleep deprivation. The authors have no proprietary or commercial interest in any materials discussed in this article.

Mentorship: Perspectives Through the Eyes of the Mentee and Mentor.

Time can be a great friend when one is young and a solemn reminder of the finality of life when one is old. Some young surgeons look at older surgeons and silently ask when will that old surgeon retire, while old surgeons see the young surgeons and wonder when will they grow up. Exploring the views from the old and young surgeon’s perspective highlights the career-altering and life-changing impact that mentors and mentees make on each other. “You gotta play this game with fear and arrogance,” were the parting words of the veteran minor league baseball player Crash Davis to the rookie Ebby Calvin “Nuke” LaLoosh as he departs for the Major Leagues (Baseball) in the 1988 movie Bull Durham. The first years in surgical practice, in many ways, resembles a rookie season. Mistakes made in residency and fellowship are erased, and a fresh start ensues. A clean record commences, and a legacy is built that follows the surgeon for their entire professional career. Navigating this journey can be tumultuous and often results in both professional and personal stress. There are 2 opposing pitfalls that young surgeons can suffer from. The first is relying solely on what was learned in training and treating every situation in the same manner because they are good at it. This is the pitcher overly relying on a 100+ mph fastball or the surgeon who uses a volar locking plate for every type of distal radius fracture. The second is being so enamored with new fads or procedures that they move from one to the next without mastering their craft. Mentors ground us in reality regarding novel procedures and devices, having the longevity and insight to see concepts being reintroduced without regard to prior failed experiences. To some extent, a mentor has to allow the mentee to make their own mistakes and learn from them. Failure followed by critical evaluation is requisite for growth and is a consistent pathway to enduring success. Therefore, the initial burden is on the mentee to keep an open mind and accepting attitude, as a tremendous amount of wisdom can be imparted which may be easily viewed as criticism. As time ensues, the mentor-mentee relation must take 1 of 3 distinct paths. The ideal path is where the mentor and mentee grow to become colleagues then equals, and as both grow the roles gradually reverse, where the older surgeon learns from the younger and is being introduced to new ways of honing the craft: the mentor becomes the mentee and visa versa. The second path is a quiet separation with each going their own way with little communication or commonality—a safe and nonconfrontational resolution. The final path is a difficult one where the mentor will not or cannot give up their role to the rising mentee and often results in a collapse and destruction of the entire relationship—a scenario every surgeon is aware of and knows about but never discusses. As the rookie surgeon grows into a seasoned surgeon, it is the mentor’s burden to be the one with an open mind and accepting attitude, allowing for continued growth for both. A mentor like Crash ensure that young surgeons continues to hone their craft, maximizes professional opportunities, and fulfill responsibilities to their profession and personal lives. Ideally, the mentor becomes the mentee over time but continually serves as a safe haven that the mentee can come back to again and again as he or she ventures out into practice with the fear of failure and the arrogance to advance the field of hand surgery. Dedicated to our mentor, friend, and colleague: Allen T. Bishop, MD, A mentor of mentors.

Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society.

Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS). An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol. A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol. A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Association Between Surgeon Technical Skills and Patient Outcomes

Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes. To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill. In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019. Colorectal and noncolorectal procedures. Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity. Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates. The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.

Surgical preference regarding different materials for custom-made allograft cranioplasty in patients with calvarial defects: Results from an internal audit covering the last 20 years

BackgroundSecondary cranioplasty (CP) plays a key role in restoring cranial vault anatomy and normal brain function following decompressive craniectomy (DC). The scientific literature provides only fragmentary information regarding the best timing and material for CP, making a direct comparison of different materials difficult. ObjectTo identify and report according to STROBE guidelines local trends in choice of materials for CP, complications rate and surgical outcomes. MethodsWe conducted an audit on secondary CP covering the last 20 years of surgical practice at our Institution. Custom-made CP used over the years were made of: porous hydroxyapatite (PHA), polymetylmethacrylate (PMMA), polyetheretherketone (PEEK), acrylic and titanium. The primary endpoint of this study was the incidence of postoperative complications, such as: implant infection, fracture and dislocation. Secondary endpoints were the followings: patients satisfaction with cosmetic result, rate of implant integration, and long-term neurological outcome. ResultsA total of 218 patients were included, given the predominance of PHA (Group A) or PMMA (Group B) CP, a direct comparison was made only between those two groups. Overall reoperation rate was 6.5% versus 28%; implants’ osseointegration rate was of 69% versus 24%; satisfaction rate was 66% versus 44%, in Group A and B respectively. ConclusionsThis single-centre study provides Level 3 evidence that PHA yields better outcomes than PMMA CP. Designing a management algorithm for planning and executing CP is difficult for clinical and organizational reasons; till a widespread consensus is reached, neurosurgeons with subspecialty interest in neurotrauma should favor pragmatism and patient safety over costs.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2min. The mean time to aortic occlusion for all surgeons was 111s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

Optimistic bias: the more you do, the better you think it goes. Survey analysis of reverse shoulder arthroplasty.

ObjectiveEven though heuristics are very helpful, several biases have been described related to their use. The aim of this study is to analyze the influence of surgery volume on the surgeon’s perception of pain improvement in patients after having received a reverse total shoulder arthroplasty.DesignSuccessive independent samples study.SettingShoulder surgeons attending four shoulder meetings.Participants149 Shoulder surgeons were included.InterventionPhysicians were asked to postulate the preoperative and postoperative pain of patients receiving a reverse shoulder arthroplasty and respond by putting a mark on two visual pain scales.Main outcome measuresPain improvement, years of shoulder practice, number of shoulder studies read over 6 months and the number of reverse shoulder arthroplasties performed per year. To compare the answers of the survey-study, a cohort of 95 patients who had undergone reverse shoulder Arthroplasty because of a rotator cuff arthropathy were prospectively followed.ResultsRegarding the pain score before and after surgery, the patient cohort showed a mean improvement of 6.84 points. In terms of the doctors, the more years of surgical practice, led them to have a greater expectation of improvement (p=0.004). Moreover, the greater the number of prostheses they implanted, the greater the expectation of improvement (p=0.0005). It was the same in terms of the number of studies read by them (p=0.001).ConclusionsYears of practice, hospital position and the number of shoulder arthroplasties done per year all favor the surgeon’s perception that their patients obtain a greater pain relief after receiving a shoulder arthroplasty than the real improvement in pain relief the patients experience.

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members.

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361-367.].

Principes généraux de la chirurgie plastique pédiatrique. Expérience tirée de 30 ans de pratique chirurgicale

In this document, Pr Guy Magalon presents a reflection on the plastic pediatric surgery drawn from 30years of surgical practice. His thinking is supported by several examples of plastic surgery results from children reviewed in adulthood. These cases highlight the evolution of surgical practices and the need for continuing education for surgeons to adapt to technical progress. Professor Magalon honors his masters and shares his personal vision of the principles of pediatric plastic surgery.

Predictors of pediatric surgeons’ career satisfaction

Objective: A survey was performed to identify factors for professional career satisfaction and for dissatisfaction. Methods: During General Assembly of CSPS, attendees answered the 37-question form grouped into the following categories: demographic, professional activity and organizational issues, type of service, education, and compensation and status. Data were analyzed using the Pearson x 2 test ( P < 0.05). Results: The response rate was 74.5% ( n = 44/59). The average age was 46 years, and 91% were male. The average participant had 17 years of surgical practice, worked 8.5 hours daily and 208 hours monthly, in children’s (49%), university (35%), or community (16%) hospital. Pediatric surgeons were satisfied with professional career (77%), and 88% would chose the same profession again. Patient satisfaction (85%), quality of care (79%), and professional achievements (76%) were rated very high. Dissatisfaction responders pointed at shortage of time for effective communication (69%), excessive administrative work (88%), too many working hours (73%), professional burnout (66%), and technical issues – IT technology (73%) and equipment (79%) out of date or old/unsuitable facilities (73%). An overall 57% of responders had presented paper on international congresses, and 32% had published paper in indexed journals. Two major concerns about education are insufficient training (61%) and lack of time for continuous education (79%). Conclusion: Pediatric surgeons are satisfied with professional career. Patient care is a leading area of satisfaction. Educational, organizational, technical, and structural issues need improvements. A large pay gap exists between expectations and real income. Keywords: pediatric surgeons, professional career satisfaction, risk factors for dissatisfaction

Infection control in colon surgery.

The aim of this study is to provide a comprehensive review of strategies that should be employed in the prevention of infection at the surgical site in patients undergoing colon surgery. The world's literature on the pathogenesis and prevention of infections at the surgical site in colon resection were reviewed to identify those methods that are associated with improved rates of infection at the surgical site. The pathogenesis, microbiology, diagnosis, and surveillance of surgical site infection have been reviewed in the context of better understanding the accepted methods for prevention. Recommendations are provided based upon evidence-based information when available. Surgical site infection rates in colon surgery have been reduced consistently over the last 60years of surgical practice. Preoperative and intraoperative techniques are described which have been useful in this improvement, while postoperative methods including the extension of postoperative systemic antibiotics have not been of value. Many methods have been demonstrated to improve surgical site infection rates in colon surgery. However, consistent and standardized applications of these principals in prevention currently do not exist. Application of evidence-based practices can further reduce the morbidity and cost of infection following colon surgery.

Fundamental Use of Surgical Energy (FUSE) certification: validation and predictors of success.

The Fundamental Use of Surgical Energy (FUSE) program includes a Web-based didactic curriculum and a high-stakes multiple-choice question examination with the goal to provide certification of knowledge on the safe use of surgical energy-based devices. The purpose of this study was (1) to set a passing score through a psychometrically sound process and (2) to determine what pretest factors predicted passing the FUSE examination. Beta-testing of multiple-choice questions on 62 topics of importance to the safe use of surgical energy-based devices was performed. Eligible test takers were physicians with a minimum of 1 year of surgical training who were recruited by FUSE task force members. A pretest survey collected baseline information. A total of 227 individuals completed the FUSE beta-test, and 208 completed the pretest survey. The passing/cut score for the first test form of the FUSE multiple-choice examination was determined using the modified Angoff methodology and for the second test form was determined using a linear equating methodology. The overall passing rate across the two examination forms was 81.5%. Self-reported time studying the FUSE Web-based curriculum for a minimum of >2 h was associated with a passing examination score (p < 0.001). Performance was not different based on increased years of surgical practice (p = 0.363), self-reported expertise on one or more types of energy-based devices (p = 0.683), participation in the FUSE postgraduate course (p = 0.426), or having reviewed the FUSE manual (p = 0.428). Logistic regression found that studying the FUSE didactics for >2 h predicted a passing score (OR 3.61; 95% CI 1.44-9.05; p = 0.006) independent of the other baseline characteristics recorded. The development of the FUSE examination, including the passing score, followed a psychometrically sound process. Self-reported time studying the FUSE curriculum predicted a passing score independent of other pretest characteristics such as years in practice and self-reported expertise.

The Influence of Volume and Experience on Individual Surgical Performance

To systematically review studies evaluating the influence of surgical experience on individual performance. Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specific manner. Performance may deteriorate toward the end of a surgeon's career.

Operative Agreement on Lateral Compression-1 Pelvis Fractures. A Survey of 111 OTA Members

To better characterize operative agreement and disagreement among orthopaedic surgeons treating lateral compression type 1 (LC-1) pelvic fractures in an effort to improve communication between care providers and improve patient care. Decision analysis. Level 1 trauma center. Twenty-seven LC-1 cases were selected to represent a wide array of LC-1 injuries. Each case was presented with 3 plain pelvic radiographs (anteroposterior, inlet, and outlet) and a scrollable computed tomography at the OTA national meeting. Attendees were queried whether they would perform operative stabilization "yes/no." Years of surgical practice (0-5, 6-10, and >10), annual pelvic fracture case volume (0-20, 21-50, and >50), and completion of a trauma fellowship (yes/no) were also collected. Fleiss' kappa (K) was used to measure operative agreement among survey respondents, where K = 0.21-0.40 was fair and K = 0.41-0.60 was moderate agreement. One hundred eleven surgeons completed the survey where the average tendency to operate across surveys was 40%. Of the 27 cases presented, only 9 cases (33%) showed substantial agreement. There were 4 cases where nearly everyone chose operative stabilization (93.1%-94.4%) and 5 cases where nearly no one chose operative stabilization (0%-8.7%). The overall agreement was fair with K = 0.39 [95% confidence interval (CI), 0.34-0.44]. Although there was a trend for surgeons with more years of surgical practice to have a lower tendency to operate, it did not achieve statistical significance (odds ratio for >10 years vs. 0-5 years = 0.73; 95% CI, 0.48-1.11). Annual case volume and completion of a trauma fellowship were not statistically significant predictors of operative tendency. Our results show only fair operative agreement (K = 0.39; 95% CI, 0.34-0.44) in a radiographic survey representing a broad range of LC-1 fracture morphologies among OTA surgeons. Only 9 of the 27 cases (33%) had substantial agreement. There was no difference in the decision to operate based on surgical volume, completion of a trauma fellowship, or time in practice. These results highlight the differing practice decisions among surgeons currently treating LC-1 injuries, and there is need for further studies to more fully understand stability after this injury pattern.

PERCEPCIONES DE LOS CIRUJANOS MÁXILOFACIALES CHILENOS ACERCA DEL DOBLE GRADO MÉDICO-DENTAL

Perceptions of chilean oral and maxillofacial surgeons about dual-degree Introduction: Dual-degree (DD) in oral and maxillofacial surgery still remains a controversial and/ or unsolved issue in many countries, although there is a growing trend towards its implementation in the developed world. The aim of this research is to describe the perceptions of Chilean oral and maxillofacial surgeons about DD and their position regarding the need of its implementation in Chile. Methodology: A cross-sectional survey was performed via the LimeSurvey web platform, included all surgeons registered in the Chilean Society. The questionnaire comprised two sections dedicated to surgical practice and perceptions about DD, respectively. Results: 67% (61) of surgeons completed the survey, main proportion men with more than 5 years of surgical practice, and experience in training teaching. 55.74% (34) considered the implemen- tation of DD programs in Chile necessary. There are correlations between this pro-DD position and hospital practice, knowledge about DD, the need for more medical skills/knowledge in daily practice, the need for DD to perform the full scope of OMS, and the opinion that Chilean training programs are not practicing at an International level. Conclusion: In Chile, as in other countries, there is a dichotomic view of DD, and it appears absolutely possible to initiate a propositive discussion about it.

Alterações posturais em cirurgiões provocadas pela atividade profissional

INTRODUÇÃO: Qualquer desvio da postura padrão é considerado alteração postural, o que não é necessariamente classificado como doença, embora afete consideravelmente a qualidade de vida dos profissionais cirurgiões. O objetivo deste estudo foi avaliar o alinhamento e o controle posturais de médicos cirurgiões e não-cirurgiões, a fim de identificar e quantificar o posicionamento dos segmentos corporais e averiguar comparativamente possíveis alterações posturais. MÉTODO: Participaram do estudo 30 sujeitos no grupo teste (CI), que atenderam aos seguintes critérios de inclusão: ser médico, idade entre 30 anos e 60 anos, com, no mínimo, 2 anos de prática cirúrgica e 4 cirurgias semanais com duração de 2 horas cada uma. O grupo comparativo (CL) constituiu-se de 32 sujeitos, médicos clínicos, com idade similar ao do grupo CI. O grupo controle (CO) constituiu-se de 33 sujeitos não-médicos, com a mesma faixa etária dos grupos CL e CI, que atendiam aos seguintes critérios de exclusão: presença de dor musculoesquelética crônica ou dor aguda intensa; diagnóstico ou sequela de doença ortopédica, reumatológica ou respiratória; ou utilização de prótese. RESULTADOS: Observou-se alta incidência de alterações posturais no grupo CI, como joelho varo, hiperextensão, hiperlordose lombar e pé com maior apoio em calcâneo, além de outros desalinhamentos. Os resultados indicam que as atividades dos cirurgiões podem ser consideradas de risco para o sistema musculoesquelético. Por ser eminentemente cirúrgica, a especialidade de cirurgia plástica é de risco ainda maior. CONCLUSÕES: A atividade cirúrgica provoca alterações posturais progressivas nos cirurgiões, podendo reduzir a vida útil na profissão e prejudicar a qualidade de vida.

A New Prosthetic Implant for Inguinal Hernia Repair: Its Features in a Porcine Experimental Model

Even after more than 100 years of inguinal hernia repair, the rate of complications and recurrence remains unacceptably high. In the last decades, few effective advances in surgical technique and materials have been made. The authors see them as minor adjustments in the shape and materials of the prosthetic implants. Still, the underlying genesis of inguinal hernia remains undefined. Based upon this, it seems the surgical repair of inguinal protrusions cannot be based upon the pathogenesis because the etiology to date has not been addressed. Most hernia repairs are performed with some degree of point fixation (sutures/tacks) to stop the mesh from migrating and creating high recurrence rates. This should be a priority for our considerations, as fixating mesh puts it in stark contrast to the physiology and dynamics of the myotendineal structures of the groin. Following years of surgical practice, implant fixation, mesh shrinkage, and poor quality of tissue ingrowth still represent an unresolved issue in modern hernia repair. Conventional prosthetics used for inguinal hernia repair are static and passive. They do not move in harmony with the dynamic elements of the groin structure and, as a result, induce the ingrowth of thin scar plates or shrinking regressive tissue that colonizes the implants. The authors strongly believe that these characteristics may be a contributing factor for recurrences and patient discomfort. Other complications are reported in the literature to be a direct result of fixation of the implants, such as bleeding, nerve entrapment, hematoma, pain, discomfort, and testicular complications. To improve results by respecting the physiology and kinetics of the inguinal region, we felt that a new type of prosthesis should be designed that induces a more structured tissue ingrowth similar to the natural biologic components of the abdominal wall. This prosthetic device was specifically designed to be placed with no point fixation. This was achieved by using inherent radial recoil, vertical buffering, friction, and delivering the device in a constrained state. A secondary benefit of this "dynamic" design is that the implant moves in a three-dimensional way in unison with the movements of the myotendineal structures of the groin. The results appear to show that the three-dimensional structure not only acts as a suitable scaffold for a full thickness ingrowth of a tissue barrier but also seems to induce an ordered, supple, elastic tissue, which allows for neorevascularization and neoneural growth. The outcomes indicate a reduced impact of fibrotic shrinkage on the implant/scar tissue when compared with shrinkage of polypropylene meshes reported in the literature. This pilot study shows the features of such an implant in a porcine experimental model.

Visual Loss After Blepharoplasty: Incidence, Management, and Preventive Measures

Although rare, instances of visual loss after cosmetic blepharoplasty have been previously reported in the literature. The goal of this study is to summarize the existing literature and report the results of a physician survey in order to provide appropriate guidelines for preventing, diagnosing, and treating this unfortunate complication. A 13-question survey was sent to all members of the American Society for Aesthetic Plastic Surgery (ASAPS) and the British Association of Aesthetic Plastic Surgery (BAAPS). Surgeons were queried about their number of years in surgical practice, their average annual caseload of blepharoplasties, and the number of cases of visual loss. The survey also contained questions about the type of anesthesia administered, surgical technique, the presence of risk factors or comorbidities in patients, symptoms, time of presentation, management, and final outcome. A total of 648 responses were received from ASAPS members and 72 from BAAPS members. The overall number of blepharoplasties reported by these respondents was 752,816. Thirty-nine cases of visual loss were reported: 25 permanent and 14 temporary. According to this, the overall incidence of visual loss following blepharoplasty was calculated at 0.0052% (five of 100,000 cases, or one in 20,000). Permanent visual loss was calculated at 0.0033% (three in 100,000, or one in 30,000) and temporary visual loss at 0.0019% (two in 100,000, or one in 50,000). The most common symptoms in affected patients were pain and pressure. Development of symptoms was reported to occur within the first 24 hours, with two peaks: intraoperative to one postoperative hour, and six to 12 postoperative hours. Hypertension was the most common risk factor for postoperative visual loss. Retrobulbar hemorrhage was reported to be the main cause of blindness. The most common management technique reported was orbital decompression, followed by steroids and canthotomy. According to this study, blindness after blepharoplasty is a rare event. However, every step should be taken to prevent it. Prevention should begin in the preoperative period and should continue intraoperatively and postoperatively. Once the diagnosis of impending visual loss is made, it should be treated as a true surgical emergency, since early treatment has proven beneficial.

The Surgeon's Expertise-Outcome Relationship in Gastric Cancer Surgery

The surgical caseload or duration of practice of a surgeon may influence the outcomes of gastric cancer surgery. This study aimed to clarify the surgical quality provided by specialized gastric cancer surgeons. The postoperative courses of 1,877 patients who underwent surgery for gastric cancer were retrospectively reviewed. For classification of the surgeon's expertise, the number of yearly resections performed by, and consecutive years of practice of, the surgeons were used. The outcome measures used were the 30-day mortality and long-term survival. Surgical mortalities of patients who underwent surgery by a specialized surgeon and those by a general surgeon revealed no statistically significant difference. A significant difference in the five-year survival rates was found with surgeons with at least two consecutive years of practice compared to those with less than two years, when 50 or more cases had been conducted per year (63.9% and 59.7%; p=0.0380). In cases of four-years of consecutive practice, the five-year survival rate was significantly improved, even if only 10 cases were performed annually (64.9% and 58.3%; p=0.0023), although the best survival rate was found with surgeons that had performed 50 or more surgeries per year. Improved survival rates, with acceptable surgical mortality, can be achieved for gastric cancer when the surgery is performed by a specialized surgeon. A specialized gastric cancer surgeon can be defined as one who has operated on more than 50 new cases per year, with 2 or more consecutive years of surgical practice.

Electrosurgery, Pacemakers and ICDs: A Survey of Precautions and Complications Experienced by Cutaneous Surgeons

Minimal information is available in the literature regarding the precautions implemented or complications experienced by cutaneous surgeons when electrosurgery is used in patients with pacemakers or implantable cardioverter-defibrillators (ICDs). The literature pertinent to dermatologists is primarily based on experiences of other surgical specialties and a generally recommended thorough perioperative evaluation. To determine what precautions are currently taken by cutaneous surgeons in patients with pacemakers or ICDs, and what types of complications have occurred due to electrosurgery in a dermatologic setting. In the winter of 2000, a survey was mailed to 419 U.S.-based members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). A total of 166 (40%) surveys were returned. Routine precautions included utilizing short bursts of less than 5 seconds (71%), use of minimal power (61%), and avoiding use around the pacemaker or ICD (57%). The types of interference reported were skipped beats (eight patients), reprogramming of a pacemaker (six patients), firing of an ICD (four patients), asystole (three patients), bradycardia (two patients), depleted battery life of a pacemaker (one patient), and an unspecified tachyarrhythmia (one patient). Overall there was a low rate of complications (0.8 cases/100 years of surgical practice), with no reported significant morbidity or mortality. Bipolar forceps were utilized by 19% of respondents and were not associated with any incidences of interference. Significant interference to pacemakers or ICDs rarely results from office-based electrosurgery. No clear community practice standards regarding precautions was evident from this survey. The use of bipolar forceps or true electrocautery are the better options when electrosurgey is required. These two modalities may necessitate fewer perioperative precautions than generally recommended, without compromising patient safety.