Open inguinal hernia repair outcomes in liver transplant recipients versus patients with cirrhosis.

PURPOSE: Patients with liver cirrhosis (LC) are at an increased risk for postoperative complications after open inguinal hernia repair (OIHR). It is possible that orthotopic liver transplant (OLT) recipients may have better outcomes, given reversal of liver failure pathophysiology. Therefore, we sought to compare mortality risk, complications, length of stay (LOS), and cost associated with OIHR in OLT recipients versus LC. METHODS: From the National Inpatient Sample (NIS), using ICD-9 codes, we found 83 OLT recipients and 764 patients with LC who underwent OIHR between 2002 and 2014. We used logistic, negative binomial, and multiple linear regression models to compare peri-operative mortality risk, postoperative complications, and LOS, and cost associated with OIHR in OLT recipients versus LC patients. Models were adjusted for patient demographic and clinical characteristics, and hospital factors. RESULTS: OLT recipients were younger (58 vs 61, p = 0.02), more likely to be privately insured (42.0% vs 24.6%, p = 0.006), less likely to have ascites at time of surgery (5.1% vs 18.9%, p = 0.003), and have surgery at large (84.3% vs 65.2%, p = 0.01) and teaching hospitals (84.2% vs 47.9%, p < 0.001). There were no mortalities among OLT recipients, but 19 (2.5%) deaths among LC patients. OLT recipients had a similar risk of overall complications (adjusted odds ratio aOR = 0.71 1.30 2.41) and hospital-associated costs (adjusted cost ratio = 0.71 0.88 1.09). However, LOS was significantly different with OLT recipients having shorter LOS (adjusted LOS ratio = 0.56 0.70 0.89). CONCLUSION: Delaying OIHR in patients with LC until after OLT decreases LOS and may carry decreased mortality.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair.

BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

ANTECEDENTES: La nomenclatura de la inserción de una malla para la reparación de una hernia incisional ventral (ventral hernia, VH) es inconsistente y confusa. En la literatura indexada se usan varios términos, tales como 'inlay', 'sublay', y 'underlay' que pueden referirse a los mismos planos anatómicos. Este hecho frustra las comparaciones de técnicas quirúrgicas e invalida los metaanálisis que comparan resultados quirúrgicos en función del plano de inserción de la malla. En consecuencia, el objetivo de este estudio fue establecer una clasificación internacional de los planos de la pared abdominal (International Classification of Abdominal Wall Planes, ICAP). MÉTODOS: Se realizó un estudio Delphi, en el que participaron 20 cirujanos de pared abdominal reconocidos internacionalmente. Se identificaron diferentes términos que describían los planos de la pared abdominal anterior mediante la revisión de la literatura y el consenso de expertos. La lista inicial incluía 59 términos posibles. Los panelistas completaron un cuestionario que sugería una lista de opciones para los planos individuales de la pared abdominal. El consenso sobre un término fue predefinido cuando dicho término había sido seleccionado por ≥ 80% de panelistas. Se eliminaron los términos con una puntuación < 20%. RESULTADOS: La votación comenzó en agosto de 2018 y se completó en enero de 2019. Durante la Ronda 1, 43 (73%) términos fueron seleccionados por < 20% de los panelistas y se sugirieron 37 términos nuevos, dejando 53 términos para la Ronda 2. Cuatro planos alcanzaron un consenso en la Ronda 2 con los términos 'onlay', 'inlay', 'pre-peritoneal' e 'intra-peritoneal'. Treinta y cinco (66%) términos fueron seleccionados por < 20% de los panelistas y fueron eliminados. Después de la Ronda 3, se logró un consenso para 'anterectus' (ante-recto), 'interoblique' (inter-oblicuo), 'retrooblique' (retro-oblicuo) y 'retromuscular'. Se alcanzó un consenso por defecto para los planos 'retrorectus' (retro-recto) y 'transversalis fascial' (fascial transverso). CONCLUSIÓN: La ICAP ha sido desarrollada por el consenso de 20 cirujanos reconocidos internacionalmente. Su implementación debería mejorar la comunicación y la comparación entre cirujanos y estudios de investigación.

Surgineering: curriculum concept for experiential learning in upper-level biomedical engineering.

PURPOSE: A strong foundation in the fundamental principles of medical intervention combined with genuine exposure to real clinical systems and procedures will improve engineering students' capability for informed innovation on clinical problems. To help build such a foundation, a new course (dubbed Surgineering) was developed to convey fundamental principles of surgery, interventional radiology (IR), and radiation therapy, with an emphasis on experiential learning, hands-on with real clinical systems, exposure to clinicians, and visits to real operating theaters. The concept, structure, and outcomes of the course of the first run of the first semester of the course are described. METHOD: The course included six segments spanning fundamental concepts and cutting-edge approaches in a spectrum of surgical specialties, body and neurological IR, and radiation therapy. Each class involved a minimum of didactic content and an emphasis on hands-on experience with instrumentation, equipment, surgical approaches, anatomical models, dissection, and visits to clinical theaters. Outcomes on the quality of the course and areas for continuing improvement were assessed by student surveys (5-point Likert scores and word-cloud representations of free response) as well as feedback from clinical collaborators. RESULT: Surveys assessed four key areas of feedback on the course and were analyzed quantitatively and in word-cloud representations of: (1) best aspects (hands-on experience with surgeons); (2) worst aspects (quizzes and reading materials); (3) areas for improvement (projects, quizzes, and background on anatomy); and (4) what prospective students should know (a lot background reading for every class). Five-point Likert scores from survey respondents (16/19 students) indicated: overall quality of the course 4.63 ± 0.72 (median 5.00); instructor teaching effectiveness 4.06 ± 1.06 (median 4.00); intellectual challenge 4.19 ± 0.40 (median 4.00); and workload somewhat heavier (62.5%) compared to other courses. Novel elements of the course included the opportunity to engage with clinical faculty and participate in realistic laboratory exercises, work with clinical instruments and equipment, and visit real operating theaters. An additional measure of the success of the course was evidenced by surveys and a strong escalation in enrollment in the following year. CONCLUSIONS: The Surgineering course presents an important addition to upper-level engineering curricula and a valuable opportunity for engineering students to gain hands-on experience and interaction with clinical experts. Close partnership with clinical faculty was essential to the schedule and logistics of the course as well as to the continuity of concepts delivered over the semester. The knowledge and experience gained provides stronger foundation for identification of un-met clinical needs and ideation of new engineering approaches in medicine. The course also provides a valuable prerequisite to higher-level coursework in systems engineering, human factors, and data science applied to medicine.

Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care.

PURPOSE: Wide variation in care and costs exists regarding the management of abdominal wall hernias, with unproven benefit for many therapies. This work establishes a specialty society-based solution to improve the quality and value of care delivered to hernia patients during routine clinical management on a national scale. METHODS: The Americas Hernia Society Quality Task Force was charged by the Americas Hernia Society leadership to develop an initiative that utilizes the concepts of continuous quality improvement (CQI). A disease-based registry was created to collect information for CQI incorporating real-time outcome reporting, patient reported outcomes, stakeholder engagement, and collaborative learning methods to form a comprehensive quality improvement effort. RESULTS: The Americas Hernia Society Quality Collaborative (AHSQC) was formed with the mission to provide health care professionals real-time information for maximizing value in hernia care. The initial disease areas selected for CQI were incisional and parastomal hernias with ten priorities encompassing the spectrum of care. A prospective registry was created with real-time analytic feedback to surgeons. A data assurance process was implemented to ensure maximal data quality and completeness. Four collaborative meetings per year were established to meet the goals of the AHSQC. As of the fourth quarter 2014, the AHSQC includes nearly 2377 patients at 38 institutions with 82 participating surgeons. CONCLUSIONS: The AHSQC has been established as a quality improvement initiative utilizing concepts of CQI. This ongoing effort will continually refine its scope and goals based on stakeholder input to improve care delivered to hernia patients.

Surgical simulation: a current review.

BACKGROUND: Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

Development of a valid, cost-effective laparoscopic training program.

BACKGROUND: Practical programs for training and evaluating surgeons in laparoscopy are needed to keep pace with demand for minimally invasive surgery. METHODS: At the University of Kentucky five inexpensive simulations have been developed to train and assess surgical residents. Residents are videotaped performing laparoscopic procedures on models. Five surgeons assess the taped performances on 4 global skills. RESULTS: Creating mechanical models reduces training costs. Trainees agreed procedures were well represented by the simulations. Blinded assessment of performances showed high interrater agreement and correlated with the trainees' level of experience. Nonclinician evaluations on checklists correlated with evaluations by surgeons. CONCLUSIONS: Inexpensive simulations of laparoscopic appendectomy, cholecystectomy, inguinal herniorrhaphy, bowel enterotomy, and splenectomy enable surgical residents to practice laparoscopic skills safely. Obtaining masked, objective, and independent evaluations of basic skills in laparoscopic surgery can assist in reliable assessment of surgical trainees. The simulations described can anchor an innovative educational program during residency for training and assessment.

Determinants of competency judgments by experienced laparoscopic surgeons.

BACKGROUND: The definitive criteria for assessing competence remain elusive. In our study, we aimed to identify the determinants of competence assessment used by individual laparoscopic surgeons. METHODS: In a blinded fashion, five laparoscopic surgeons rated 27 subjects on three laparoscopic simulations in four skill categories: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. The raters then assessed overall subject competence for each procedure. Point-biserial correlational analyses and cluster analyses were performed to ascertain the relationships among the various scales. RESULTS: All of the correlations between the skills' ratings and competence judgments were statistically significant ( p <.05). No skill rating was consistently more highly correlated with the competence rating. There were no distinct patterns of correlations for each rater or each procedure. One factor emerged from each cluster analysis of the skills measures. CONCLUSIONS: The results suggest that the four skills scored in the study are highly correlated with each other and are important in determining competence. The cluster analyses revealed that the surgeon raters shared a common perception of competence.

Multimedia article. Laparoscopic Ladd's procedure in two adults: malrotation and the minimally invasive approach.

Malrotation is an intestinal rotation anomaly rarely diagnosed in adults. In the adult patient, obstructing peritoneal bands may lead to nausea and abdominal distention. Familiarity with this presentation as well as the aberrant anatomy associated with the unusual problem facilitates surgical treatment. While the minimally invasive approach requires meticulous dissection due to this abnormal anatomy, laparoscopic treatment does provide the advantages of short convalescence and low morbidity. This video briefly reviews embryologic intestinal development, rotational anomalies and two laparoscopic Ladd's procedures.

Evaluating minimally invasive surgery training using low-cost mechanical simulations.

BACKGROUND: The goal of this study was to develop, test, and validate the efficacy of inexpensive mechanical minimally invasive surgery (MIS) model simulations for training faculty, residents, and medical students. We sought to demonstrate that trained and experienced MIS surgeon raters could reliably rate the MIS skills acquired during these simulations. METHODS: We developed three renewable models that represent difficult or challenging segments of laparoscopic procedures; laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), and laparoscopic inguinal hernia (LH). We videotaped 10 students, 12 surgical residents, and 1 surgeon receiving training on each of the models and again during their posttraining evaluation session. Five MIS surgeons then assessed the evaluation session performance. For each simulation, we asked them to rate overall competence (COM) and four skills: clinical judgment (respect for tissue) (CJ), dexterity (economy of movement) (DEX), serial/simultaneous complexity (SSC), and spatial orientation (SO). We computed intraclass correlation (ICC) coefficients to determine the extent of agreement (i.e., reliability) among ratings. RESULTS: We obtained ICC values of 0.74, 0.84, and 0.81 for COM ratings on LH, LC, and LA, respectively. We also obtained the following ICC values for the same three models: CJ, 0.75, 0.83, and 0.89; DEX, 0.88, 0.86, and 0.89; SSC, 0.82, 0.82, and 0.82; and SO, 0.86, 0.86, and 0.87, respectively. CONCLUSIONS: We obtained very high reliability of performance ratings for competence and surgical skills using a mechanical simulator. Typically, faculty evaluations of residents in the operating room are much less reliable. In contrast, when faculty members observe residents in a controlled, standardized environment, their ratings can be very reliable.

Changes in postural mechanics associated with different types of minimally invasive surgical training exercises.

BACKGROUND: Doctors who perform minimally invasive surgery commonly report upper extremity fatigue or joint and muscle pain. The goal of this study was to investigate the changes in postural parameters associated with different laparoscopic training tasks and graspers. METHODS: Three different training tasks (targeted object release, rope passing, and cable tying) were performed with three types of laparoscopic graspers. Joint angles were determined using video analysis, and centers of pressure (COP) were measured with force platforms. RESULTS: Cable tying proved to be the most challenging training task and involved greater joint angle excursions and COP excursions and velocities. Grasper 2 reduced shoulder and wrist flexion-extension over the selected tasks. CONCLUSION: Training tasks should be designed to simulate surgical procedures because different tasks require distinct combinations of joint rotations. Joint rotations and postural balance should be considered when an optimal grasper is selected for a particular training task.

Laparoscopic repair of traumatic diaphragmatic injuries.

BACKGROUND: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. METHODS: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15-63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0-6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5-420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). RESULTS: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5-12 cm). The mean operative time was 134.7 min (range, 55-200 min). The mean estimated blood loss was 108.5 ml (range, 30-500 ml), and the postoperative length of stay was 4.4 days (range, 1-12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6-14 days). CONCLUSIONS: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.

The effect of using laparoscopic instruments on muscle activation patterns during minimally invasive surgical training procedures.

BACKGROUND: Many surgeons report pain as a result of muscle fatigue during laparoscopy. Therefore, determining how surgical task or instrument selection influences the duration of muscle activation may provide insight into the relationship between laparoscopic instrumentation and muscle fatigue. METHODS: Surface electromyography (EMG) electrodes were placed over the right deltoid, trapezius, bicep, pronator teres, flexor carpi ulnaris, and extensor digitorum superficialis muscles of four surgeons. These surgeons were then asked to perform a targeted grasp and release (T1), a simulated bowel inspection (T2), and a cable-tying exercise (T3) while using three different inline finger-looped graspers. The graspers included a nonratcheted handle with a single-action blunt-end effector (G1) and two models that had ratcheted handles with dual-action end effectors (G2, G3). Resting and maximal voluntary contraction EMG values for each muscle were used to normalize the data and to determine percentage of activation during each task. A multivariate analysis of variance (ANOVA) was used to compare EMG relative time of activation (RAT) patterns with grasper, task, and grasper and task interaction. RESULTS: In general, when grasper and task were considered individually, G1 and T3 demonstrated the highest RAT. Findings showed that RAT was most affected by the use of either G1 or G2 during T2 or T3. CONCLUSION: Task, grasper, and the interaction between grasper and task all appear to influence the RAT and therefore, to varying degrees, all three may play a role in influencing muscle fatigue.

Laparoscopic pancreatic cystgastrostomy via the lesser sac approach.

Laparoscopic cystgastrostomy offers the benefits of a minimally invasive procedure while providing effective drainage for pancreatic pseudocysts. The lesser sac approach to laparoscopic cystgastrostomy provides adequate working space with excellent visualization. This assures meticulous hemostasis, debridement of the cyst, and wide internal drainage of the pancreatic pseudocyst. Additionally, the laparoscopic approach to this difficult problem can be augmented by other minimally invasive therapies. This video outlines the management of a patient with a pancreatic pseudocyst and concomitant splenic vein thrombosis treated with preoperative splenic embolization and laparoscopic cystgastrostomy via the lesser sac approach.

Guidewire incidents with inferior vena cava filters.

Several authors have demonstrated that prophylactically inserted inferior vena cava filters have decreased pulmonary thromboembolic complications in selected high-risk trauma patients. Guidewire-related mishaps are potential complications of inferior vena cava filters and are likely underreported. The authors present two cases and review strategies to prevent these complications.

Is surgical excision necessary for atypical ductal hyperplasia of the breast diagnosed by Mammotome?

BACKGROUND: Core biopsy findings of atypical ductal hyperplasia (ADH) underestimates the diagnosis of malignancy by 18% to 88%. Using the Mammotome biopsy technique, more accurate assessment of the lesion is possible, making selective excision of these lesions a consideration. METHODS: The records of 62 patients who were found to have ADH at Mammotome biopsy and subsequently underwent excision of the lesion were reviewed. Patient data were statistically analyzed for predictors of malignancy at the time of surgical excision. RESULTS: Of the 62 patients, 9 (15%) had malignancy at excision. Variables predicting for malignancy included markedly atypical hyperplasia and incomplete removal of calcifications at Mammotome biopsy, a previous contralateral breast cancer, and a family history of breast cancer, with a combined sensitivity of 100% and specificity of 80%. CONCLUSIONS: Mild ADH found on Mammotome, not associated with a personal or family history of breast cancer, may not need excision if all calcifications have been removed.