Surgical Inpatient's Attitudes Toward Resident Participation: All About Expectations.

OBJECTIVE: Determine whether an educational video can improve surgical inpatients' attitudes toward resident participation in their care. METHODS: Patients admitted to the Trauma/Emergency General Surgery Service at University Hospital (San Antonio, Texas) were randomly divided into control and intervention groups. Patients in the intervention group viewed a short educational video about the role and responsibilities of medical students, residents, and attending surgeons. All patients then completed a previously published survey. RESULTS: A total of 140 patients responded to the survey (control = 81 and intervention = 59 patients). Overall, 86.4% of patients were welcoming of resident participation. Patients who were expecting residents to be involved in their care had attitudes that are more favorable on almost all survey questions regardless of their study condition. However, patients in the intervention group who expected resident involvement in their care had more favorable attitudes about senior residents (postgraduate year 3-5) assisting in routine or complicated surgery than those in the control group who were expecting resident involvement (both p ≤ 0.001). This same group of patients also had more favorable attitudes about surgical outcomes and overall surgical health when residents are involved (p = 0.004, p = 0.001, respectively). Most patients (79%) said they had no residents previously involved in their care, or they were unsure if residents were previously involved. CONCLUSIONS: Patient expectation of resident involvement is one of the most important factors influencing perceptions of inpatients about resident participation in surgery. Our goal should be early and frequent discussion with patients about resident involvement in order to foster an atmosphere of trust, including full transparency regarding resident involvement in surgical procedures. An educational video may help introduce the roles of trainees and attending surgeons but should not be used in lieu of direct discussion with patients.

Resident training experience with robotic assisted transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: General surgery is the fastest growing field in the adoption of robotic assisted laparoscopic surgery. Here, we present the results of one institution's experience in training surgical residents in robotic assisted transabdominal preperitoneal inguinal hernia repairs. METHODS: Data were prospectively collected on patients undergoing robotic assisted laparoscopic inguinal hernia repair with residents. Data points included patient age, gender, complications, hernia difficulty, resident technical competency as measured by GEARS, Zwisch scores, operative time, and the number of robotic console cases reported by residents as primary surgeon. RESULTS: Residents who performed >30 robotic cases had significantly higher mean modified GEARS scores (p ≤ .002). Residents who completed 10 or fewer robotic cases achieved significantly lower mean modified GEARS and Zwisch scores than those who completed 11 or more (p < .001). CONCLUSIONS: Resident competency and autonomy improve with increasing total robotic case load. Attending surgeons grant more autonomy to residents with higher competency scores.

Primary Desmoid Tumor of the Small Bowel: A Case Report and Literature Review.

Desmoid tumors, also known as aggressive fibromatosis, are fibromuscular neoplasms that arise from mesenchymal cell lines. They may occur in almost all soft tissue compartments. Primary desmoids of the small bowel are rare but potentially serious tumors presenting unique challenges to the general surgeon. We present one case of a 59-year-old man presenting with three months of abdominal distension secondary to a small bowel desmoid. Computed tomography of the abdomen showed an 18-cm mass in the mid-abdomen without obvious vital structure encasement. Percutaneous biopsy of the mass indicated a desmoid tumor. The patient underwent a successful elective exploratory laparotomy with resection and primary enteric anastomosis. Final pathology revealed the mass to be a primary desmoid of the small bowel. His post-operative course was uneventful. At two years after surgery, he is symptom free, and there is no evidence of disease recurrence. Due to the rare nature of primary small bowel desmoids, there are few specific care pathways outlined. This is a challenging pathology to treat that often requires a multidisciplinary team of surgical and medical oncologists.

Femoral Head Dislocation into the Rectum Following Blunt Trauma.

Traumatic hip dislocations require prompt diagnosis and treatment to prevent avascular necrosis of the femoral head. This injury is further complicated when there is an ipsilateral femur fracture. Here, we present what is likely the first reported case of a patient with traumatic hip dislocation and ipsilateral femur fracture with transrectal displacement of the femoral head. The patient presented to a level one trauma center in 2006 as a transfer from another facility after being thrown from a pickup truck. Upon initial evaluation, a foreign body was palpated in the rectum. Computed tomography (CT) imaging showed that the right femoral head was lodged within the pelvis. In the operating room, an exploratory laparotomy was performed, and anoscopy confirmed the placement of the femoral head within the rectal lumen. The femoral head was extracted from the rectum transanally. The operation was abbreviated, as the patient became hemodynamically unstable, and he was taken to the intensive care unit. He returned to the operating room the following day for a repeat washout and proximal diversion. Despite numerous orthopedic procedures and operative washouts, he ultimately underwent a right hip disarticulation. Physicians should be aware that intracorporeal femoral head displacement is possible in select patients who have experienced a high-energy trauma mechanism. This is a complicated, highly morbid injury that poses various management challenges to orthopedic and acute care surgeons.

Bronchoperitoneal and Enterocutaneous Fistula Development Following a Colorectal Anastomosis Leak.

Bronchoperitoneal fistulas are rare but serious pathologies that pose numerous treatment challenges to physicians. There is usually a delay in diagnosis, and treatment recommendations are mainly derived from case reports. Here, we present an interesting case of a patient who developed a left bronchoperitoneal fistula and two subsequent enterocutaneous fistulas resulting from a massive intra-abdominal phlegmon eroding through the left diaphragm. The patient experienced numerous medical complications during his hospital stay and required multiple operations. However, 18 months after his initial post-operative complication, the bronchoperitoneal fistula has healed, and the patient has undergone successful intestinal reconstruction. This case highlights multiple uncommon disease processes and the treatment strategies used.