The Impact of the COVID-19 Pandemic on Geographic Placement of Applicants to General Surgery Residency Programs.

OBJECTIVE: COVID-19 greatly influenced medical education and the residency match. As new guidelines were established to promote safety, travel was restricted, visiting rotations discontinued, and residency interviews turned virtual. The purpose of this study is to assess the geographic trends in distribution of successfully matched General Surgery applicants prior to and after the implementation of pandemic guidelines, and what we can learn from them as we move forward. DESIGN: This was a retrospective review of 129 Accreditation Council for Graduate Medical Education (ACGME) accredited, academic General Surgery Residency Programs across 46 states and the District of Columbia. Categorically matched residents' medical schools (i.e., home institutions), medical school states, and medical school regions as defined per the Association of American Medical Colleges (AAMC), were compared to the same geographic datapoints as their residency program. Preliminary residents were excluded. Residents in the 2018, 2019, and 2020 cycles were sub-categorized into the "pre-COVID" group and residents in the 2021 and 2022 applications cycles were sub-categorized into the "post-COVID" group. The percentages of residents who matched at their home institution, in-state, and in-region were examined. SETTING: Multiple ACGME-accredited, university-affiliated General Surgery Residency Programs across the United States of America. PARTICIPANTS: A total of 4033 categorical General Surgery residents were included. RESULTS: Of 4033 categorical residents who matched between 2018 and 2022, 56.1% (n = 2,263) were in the pre-COVID group and 43.9% (n = 1770) were in the post-COVID group. In the pre-COVID group 14.4% (n = 325) of residents remained in-home (IH), 24.4% (n = 553) in-state (IS), and 37.0% (n = 837) in- region (IR), compared to 18.8% IH (n = 333), 27.8% IS (n = 492), and 39.9% IR (n = 706) in the post-COVID group, respectively. Significant increases for IH and IS resident matching at 4.5% and 3.4%, respectively, were noted in the post-COVID period (p < 0.05). CONCLUSION: The COVID-19 pandemic, and the ensuing changes adopted to promote safety, significantly impacted medical student opportunities and the General Surgery residency application process. General Surgery match data over the last 5 years reveals a statistically significant increase in the percentage of applicants matching at in-home and in-state institutions after the pandemic.

Implementation of an Online Intraoperative Assessment of Technical Performance for Surgical Trainees.

INTRODUCTION: Assessment of surgical resident technical performance is an integral component of any surgical training program. Timely assessment delivered in a structured format is a critical step to enhance technical skills, but residents often report that the quality and quantity of timely feedback received is lacking. Moreover, the absence of written feedback with specificity can allow residents to seemingly progress in their operative milestones as a junior resident, but struggle as they progress into their postgraduate year 3 and above. We therefore designed and implemented a web-based intraoperative assessment tool and corresponding summary "dashboard" to facilitate real-time assessment and documentation of technical performance. MATERIALS AND METHODS: A web form was designed leveraging a cloud computing platform and implementing a modified Ottawa Surgical Competency Operating Room Evaluation instrument; this included additional, procedure-specific criteria for select operations. A link to this was provided to residents via email and to all surgical faculty as a Quick Response code. Residents open and complete a portion of the form on a smartphone, then relinquish the device to an attending surgeon who then completes and submits the assessment. The data are then transferred to a secure web-based reporting interface; each resident (together with a faculty advisor) can then access and review all completed assessments. RESULTS: The Assessment form was activated in June 2021 and formally introduced to all residents in July 2021, with residents required to complete at least one assessment per month. Residents with less predictable access to operative procedures (night float or Intensive Care Unit) were exempted from the requirement on those months. To date a total of 559 assessments have been completed for operations performed by 56 trainees, supervised by 122 surgical faculty and senior trainees. The mean number of procedures assessed per resident was 10.0 and the mean number per assessor was 4.6. Resident initiation of Intraoperative Assessments has increased since the tool was introduced and scores for technical and nontechnical performance reliably differentiate residents by seniority. CONCLUSIONS: This novel system demonstrates that an online, resident-initiated technical assessment tool is feasible to implement and scale. This model's requirement that the attending enter performance ratings into the trainee's electronic device ensures that feedback is delivered directly to the trainee. Whether this aspect of our assessment ensures more direct and specific (and therefore potentially actionable) feedback is a focus for future study. Our use of commercial cloud computing services should permit cost-effective adoption of similar systems at other training programs.

The Use of the Perioperative Nutrition Score in Postoperative Pediatric Inflammatory Bowel Disease Patients.

BACKGROUND AND OBJECTIVES: Preoperative malnutrition is associated with increased postoperative morbidity. The perioperative nutrition score (PONS) was developed to identify patients at risk of malnutrition. We sought to assess the correlation between preoperative PONS and postoperative outcomes in pediatric inflammatory bowel disease (IBD) patients. METHODS: We performed a retrospective cohort study of IBD patients, less than 21 years of age, who underwent elective bowel resection between June 2018 and November 2021. Patients were divided based upon whether they met PONS criteria. The primary outcome was postoperative surgical site infections. RESULTS: 96 patients were included. Sixty-one patients (64%) met at least one PONS criteria, while 35 patients (36%) met none. PONS positive patients more frequently received preoperative TPN supplementation (p < .001). There was no difference in preoperative oral nutritional supplementation between groups. Patients that screened positive for PONS had a longer hospital stay (p = .002), more readmissions (p = .029), and more surgical site infections (p = .002). CONCLUSIONS: Our data highlight the prevalence of malnutrition in the pediatric IBD population. Patients who screened positive had worse postoperative outcomes. Further, very few of these patients received preoperative optimization with oral nutritional supplementation. There is a need for standardization of nutritional evaluation to improve preoperative nutritional status and postoperative outcomes. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective Cohort.

Development and repair of aorto-esophageal fistula following esophageal button battery impaction: A case report.

BACKGROUND: Complications from esophageal button battery impactions remain a real fear for practicing pediatric gastroenterologists and surgeons. This case describes a child who developed an aorto-esophageal fistula 25 days after initial battery ingestion and survived due to prompt placement of an aortic stent via minimally invasive surgery, avoiding an open procedure. CASE PRESENTATION: A 6-year-old female presented acutely with a mid-esophageal button battery impaction witnessed by her parents. Presenting symptoms included chest pain and emesis. Button battery location and size were confirmed on X-ray. She underwent removal with flexible esophagogastroduodenoscopy (EGD) and rigid esophagoscopy. She was admitted to the hospital and received conservative medical management, with serial cross-sectional imaging via chest MRIs to assess the evolution of her injury according to available national guidelines, and was discharged after 12 days of close inpatient monitoring. Despite these measures the patient represented 25 days post-ingestion with hematemesis from a new aorto-esophageal fistula, requiring emergent cardiac catheterization with successful, life-saving aortic stent placement. She remained admitted for an additional 12 days of monitoring as her diet was advanced slowly post-catheterization. Since this second hospitalization she continues to do well, with outpatient follow-up by multiple subspecialists. CONCLUSIONS: This case highlights the continued uncertainty regarding the risk of developing this complication, as well as gaps in the current literature and guidelines for managing these patients following ingestion and esophageal injury. It also details the unique course following development of this complication and its surgical repair.

Multi-institutional Collaborative Surgery Education Didactics: Virtual Adaptations During a Global Pandemic.

OBJECTIVE: The COVID-19 pandemic has disrupted graduate medical education, impacting Accreditation Council for Graduate Medical Education (ACGME)-mandated didactics. We aimed to study the utility of 2 methods of virtual learning: the daily National Surgery Resident Lecture Series (NSRLS), and weekly "SCORE School" educational webinars designed around the Surgical Council on Resident Education (SCORE) curriculum. DESIGN AND SETTING: NSRLS: The National Surgery Resident Lecture Series was a daily virtual educational session initially led by faculty at an individual surgical residency program. Thirty-eight lectures were assessed for number of live viewings (March 23, 2020-May 15, 2020). SCORE SCHOOL: Attendance at eleven weekly SCORE educational webinars was characterized into live and asynchronous viewings (May 13, 2020-August 5, 2020). Each 1-hour live webinar was produced by SCORE on a Wednesday evening and featured nationally recognized surgeon educators using an online platform that allowed for audience interaction. RESULTS: NSRLS: There were a mean of 71 live viewers per NSRLS session (range 19-118). Participation began to decline in the final 2 weeks as elective case volumes increased, but sessions remained well-attended. SCORE SCHOOL: There were a range of 164-3889 live viewers per SCORE School session. Sessions have most commonly been viewed asynchronously (89.8% of viewings). Live viewership decreased as the academic year ended and then rebounded with the start of the new academic year (range 4.9%-27%). Overall, the eight webinars were viewed 11,135 times. Each webinar continues to be viewed a mean of 43 times a day (range 0-102). Overall, the eleven webinars have been viewed a total of 22,722 times. CONCLUSIONS: Virtual didactics aimed at surgical residents are feasible, well-attended (both live and recorded), and have high levels of viewer engagement. We have observed that careful coordination of timing and topics is ideal. The ability for asynchronous viewing is particularly important for attendance. As the COVID-19 pandemic continues to disrupt healthcare systems, training programs must continue to adapt to education via virtual platforms.

Correction of Lipid Metabolism Disorders in Diabetes Mellitus with Peptide Drugs.

We studied the effect of peptide drugs deltalicin and Semax on lipid metabolism disturbances in diabetes mellitus. Diabetes mellitus was modeled by single injection of streptozotocin (45 mg/kg) and rats with blood glucose ≥12 mmol/liter were selected for the further experiments. Deltalicin in a dose 100 µg/kg and Semax in a dose 200 µg/kg as well as sulodexide corrected lipid metabolism disorders: the content of total cholesterol, triglycerides, LDL, index of atherogenicity decreased and HDL concentration increased. Deltalicin produced more potent effect on lipid metabolism in rats with diabetes mellitus than sulodexide and Semax, which manifested in a significant decrease in total cholesterol and LDL concentration and index of atherogenicity.

Effects of neuromuscular electrical stimulation in critically ill patients: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVES: We performed a systematic review and meta-analysis to examine the effect of neuromuscular electrical stimulation (NES) on prevention of critical care myopathy and its effect on various clinical outcomes in the intensive care unit (ICU). REVIEW METHODS USED: This study involved systematic review and meta-analysis of randomised controlled trials (RCTs) comparing NES (applied to different muscle groups combined with usual care) and usual care (passive and active exercises along with early mobilisation and rehabilitation). Included studies enrolled adult patients managed in the ICU for medical or surgical diseases who were or were not mechanically ventilated. The primary outcome was global muscle strength measured by the Medical Research Council grading system. Secondary outcomes included ICU mortality, duration of mechanical ventilation (MV), and ICU length of stay. Risk ratio for dichotomous data and mean difference (MD) for continuous data with their corresponding 95% confidence interval (CI) were calculated. DATA SOURCE: A search in major electronic databases, including PubMed, Cochrane Library, and Embase, from inception to November 2018 was carried out. RESULTS: Six RCTs were included, representing 718 patients. The mean age 60 ± 15.3 years, and 60.6% were male. There was no significant difference between NES and usual care on global muscle strength measured by Medical Research Council grading system (MD: 0.45; 95% CI: -2.89 to 3.80; p = 0.79), ICU mortality (risk ratio: 1.30; 95% CI: 0.95-1.78; p = 0.10), duration of MV (days) (MD: -2.07; 95% CI: -5.06 to 0.92; p = 0.18), or ICU length of stay (days) (MD: -3.06; 95% CI: -9.79 to 3.68; p = 0.37) in comparison with the usual therapy alone in critically ill patients. CONCLUSION: NES combined with usual care was not associated with significant differences in global muscle strength, ICU mortality, duration of MV, or ICU length of stay in comparison with usual care alone in critically ill patients. Further RCTs are needed to determine patients with maximum benefit and to examine NES safety and efficacy.

Correction of Acute Parodontitis with Indolicidin Analogues.

We studied the influence of synthetic indolicidin analogues on the development of acute periodontitis. The corrective effect was found in indolicidin analogues Nos. 7 and 8; it manifested in a decrease in the edema of gingival epithelium and lamina propria, a decrease in the relative area of inflammatory infiltrates, and a significant increase in the relative area of normal connective tissue. These changes were revealed as soon as on day 14 and were most pronounced in 21 days after the removal of the ligature. Indolicidin analogues Nos. 7 and 8 demonstrated similar effectiveness on the model of acute periodontitis.

Enterobius vermicularis Appendiceal Colic.

Enterobius vermicularis associated appendiceal colic and acute appendicitis are rarely encountered in the United States. The 9-year-old patient described in this case presented with right lower quadrant abdominal pain, nausea, and vomiting consistent with acute appendicitis and was brought to the operating room for an appendectomy. Intraoperatively a pinworm, E. vermicularis, was visualized and the presumptive diagnosis of acute appendicitis was revised to E. vermicularis associated appendiceal colic. Retrospective review of the preoperative imaging demonstrates the first reported ultrasonographic image of pinworm inhabitance within the appendiceal lumen. The patient was treated postoperatively with a course of albendazole and recovered appropriately. This article reviews the geographic epidemiology, pathophysiology, surgical, and medical treatment recommendations in the management of E. vermicularis diseases of the appendix. Through dissemination of this ultrasonographic imaging, the authors hope to inform other providers about E. vermicularis associated appendiceal colic and reduce the incidence of avoidable surgeries.

Congenital paraesophageal hernia: Contemporary results and outcomes of laparoscopic approach to repair in symptomatic infants and children.

BACKGROUND: Congenital paraesophageal hernia (CPEH) is a rare diaphragmatic anomaly for which repair has primarily been described by laparotomy, although, more recent case series describe laparoscopic repair. In reports with over five patients, the predominant approach has been with laparotomy. The purpose of our study was to review our recent institutional experience and results with exclusively laparoscopic repair of CPEH in infants and children. METHODS: An IRB approved retrospective review of all patients with CPEH who underwent laparoscopic treatment at a tertiary children's hospital from 2010 to 2017 was performed. We included only those patients from our own institution with primary CPEH, or CPEH with prior repair (s) at other centers, with recurrence presenting for operation. Data including demographics, diagnostic studies, operative details, complications, outcomes, and follow up were analyzed. Age at diagnosis was 1 day to 25 years of age (mean 2.5 years). RESULTS: A total 28 patients underwent 30 operations to treat CPEH. All operations were completed laparoscopically with no conversions to open. There were 6 Type II, 16 Type III, and 6 Type IV CPEH patients. Seventeen patients were less than one year of age (61%). Weight at time of repair was 10.3 kg (1.2-44 kg). Twelve patients were less than 5 kg (43%), eight patients (28.5%) were less than 10 kg, and 8 were more than 10 kg (28.5%). Operative time averaged 125 min (range 61-247 min). Three patients underwent initial CPEH repair (s) (open: 2 and laparoscopic: 1) at other institutions before laparoscopic revision was performed at our hospital (11%). Crural repair was performed in all patients, fundoplication in 26 (93%) and concomitant gastrostomy was performed in 14 patients (50%). Complications included two patients with recurrent hiatal hernias, which were redone laparoscopically (2/28 or 7% recurrence) and 1 capnothorax requiring pigtail drainage postoperatively. There were no deaths, no requirement for esophageal dilations, or esophageal lengthening. One patient required laparoscopic gastrostomy six weeks post initial repair for failure to thrive. Follow-up ranged from 4 months to 8 years (average 36 months). CONCLUSION: Congenital paraesophageal hernia in infants and children is uncommon. Based on our experience, the laparoscopic approach to repair is feasible, even for neonates, with excellent results, acceptably low recurrence rate, and may even be considered for revisional operations. STUDY TYPE: Clinical research paper. LEVEL OF EVIDENCE: Type IV.

Ostomy in continuity: A novel approach for the management of children with complex short bowel syndrome.

INTRODUCTION: Despite medical and surgical management, a subset of children with short bowel syndrome (SBS) who have discrepancy between proximal small bowel and distal colon have persistent feeding intolerance. We propose the use of an Ostomy in Continuity (OIC) (Bishop-Koop or Santulli) as a salvage procedure to decompress the proximal bowel while still maintaining maximal intestinal length, in these patients. METHODS: A retrospective chart review of 104 SBS patients identified sixteen patients who underwent an OIC. Measures of reliance on parenteral nutrition (PN), growth, intestinal failure associated liver disease, the rate of central venous catheter infections and enterocolitis were collected. These parameters were compared before and after the placement of OIC in the same patients at a median follow-up period of 24months (range 3-52months). Outcome measures include intestinal autonomy and survival without intestinal and liver transplant. RESULTS: All 16 patients showed significant improvement in their enteral tolerance after OIC. The mean PN caloric requirement decreased from 95% to 21% (p=0.0001). The median weight Z score improved from -1.18 to 0.20 (p=0.0006) and the median height Z score improved from -2.74 to -1 (p=0.0001). The mean conjugated bilirubin decreased from 10.3mg/dl to 0.3mg/dl (p=0.0001) in nine patients with hyperbilirubinemia. There was no decrease in central venous catheter infections (CVCI) but there was a decrease in the rate of enterocolitis. None of the patients required intestinal or liver transplant. There was one minor skin excoriation complication in one patient with a Bishop-Koop stoma. CONCLUSIONS: The application of an ostomy in continuity within a comprehensive intestinal rehabilitation program is a novel approach in the treatment of refractory short bowel syndrome that improves intestinal autonomy and decreases the rate of enterocolitis. TYPE OF STUDY: Case Series. LEVEL OF EVIDENCE: IV (Cohort Study).

E-Mailed Conference Synopses as a Tool for Resident and Faculty Development.

OBJECTIVE: This study aims to investigate the utility and success of daily conference synopses emails ("Daily Dispatches") sent to surgical attending physicians, fellows, and residents to foster resident and faculty development. DESIGN: Emails were distributed by the surgical residency program director (PD), summarizing each day of a surgical conference. Two prospective electronic surveys were administered to surgical residents, fellows, and attending surgeons to evaluate the value of this Daily Dispatch method. SETTING: Institutional; Medstar Georgetown University Hospital, Department of Surgery, Washington, DC. PARTICIPANTS: Email synopses were sent to surgical attendings, fellows and residents. Pilot survey was distributed to 60 participants, main survey sent to 74 participants. RESULTS: The response rate for the pilot survey was 41.6% (25/60). When asked about the mode of delivery, 96% of respondents wanted to maintain the email medium when compared to a lecture, paper handout, or the use of social media. The response rate for the main survey was 31.1% (23/74). Almost all (91%) respondents reported reading the emails. Within this group, 70% "agreed" or "strongly agreed" that the emails were useful. Furthermore, 90% reported learning "at least one new thing" and 80% confirmed these "emails provide meaningful content they would not otherwise obtain". CONCLUSION: Individualized daily synopsis emails highlighting relevant content provided meaningful information from conferences to non-attendees. The emails were well received and useful. Daily Dispatches meet an important need in dissemination of information traditionally gathered only by the rate-limiting step of conference attendance.

Defining the Applicant Pool for Postgraduate Year-2 Categorical General Surgery Positions.

OBJECTIVE: In the spring of 2010, a categorical general surgery postgraduate year (PGY)-2 position became available at our academic medical center secondary to attrition of a PGY-1 resident. We sought to study the unique characteristics of applicants to that position and to describe the selection process with hopes to stimulate additional studies about the unique challenges of recruiting applicants into advanced standing positions. DESIGN: Applications were received via e-mail and reviewed to characterize the applicant pool. An Excel spreadsheet was used to organize data. Characteristics assessed included United States Medical Licensing Examination (USMLE) scores, Educational Commission for Foreign Medical Graduates status, Alpha Omega Alpha Honor Society status, sex, academic performance, number of case logs, volunteer and job experience, leadership roles, research experience including submissions, and advanced degrees. These characteristics were compared to those of the PGY-1 applicants through the Match that year. SETTING: Academic medical center. PARTICIPANTS: Applicants for a categorical general surgery PGY-2 position in 2010. RESULTS: A total of 129 applicants provided the requested documents. There were 104 males, 25 females, no Alpha Omega Alpha Honor Society candidates, and 82 international candidates. Of all, 46 candidates experienced academic difficulties. Quantitative averages include USMLE 1: 214.17, USMLE 2: 215.74, American Board of Surgery In Training Examination (ABSITE) percentile = 51.96, ABSITE 2 = 46.00, grand total case log: 192.10. Advanced degrees included 2 MBAs, 6 MPHs, and 7 nonphysiology MSs. The selection process to fill the position started on 3/25/2010 when the announcement was published and ended on 5/11/2010 when the offer of acceptance was sent. The selected applicant integrated well with the peers and just graduated from our residency as one of the leaders of the graduating class. CONCLUSIONS: Although the attrition rate in general surgery remains high, there is a dearth of literature about how best to replace residents. The hardship of replacing residents highlights the importance of studying this group to improve the recruitment process and the quality of replacement residents. The selection process was time consuming and presented its own challenges given the lack of a computerized system for screening. It lasted nearly 7 weeks requiring faculty time commitment to mine through application data/e-mails, correspond with applicants, conduct interviews, and ultimately select an applicant for the position. This is the first study to investigate the applicant pool to advanced standing positions in general surgery and we present it as a pilot study to stimulate further research efforts.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children.

PURPOSE: To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population. METHODS: A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals. RESULTS: A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0 kg (SD 2.9); mean age 10 months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n = 18). The median duration of line placement was 140 days (IQR 146). The most common indications for removal were completion of therapy (n = 7, 39%) and infection (n = 5, 28%). There were no early complications. Long-term complications included infection (n = 5) or catheter malfunction (n = 3). CONCLUSIONS: Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

Laparoscopic Excision of Congenital Hepatic Cysts in the Pediatric Population: A Case Series and Literature Review.

PURPOSE: Congenital hepatic cysts are rare. Surgical excision is indicated for symptoms, complications, and to rule out malignancy. Laparoscopic management in the pediatric population has not been extensively documented. We present a series involving laparoscopic excision of pediatric congenital hepatic cysts and review the literature. METHODS: Data were collected over 15 years from two pediatric surgeons at three medical centers. Presence of a hepatic cyst excised laparoscopically was the only inclusion criterion. Data were collected on the cyst size, type, pathology, and location, as well as on length of hospital stay, complications, and 1 year recurrence rate. RESULTS: Four patients were identified: a 7-week-old male presenting with feeding intolerance due to a hepatic cyst; a 6-year-old male presenting with a hepatic cyst identified by ultrasound during evaluation for appendicitis; a male neonate diagnosed at birth with a left thoracic cyst that communicated through the diaphragm with a hepatic cystic lesion; and a 14-year-old male presenting with a 25 cm × 11 cm hepatic cyst. All lesions were excised laparoscopically. CONCLUSION: Our series is the largest documenting complete laparoscopic excision of congenital solitary hepatic cysts in the pediatric population. Laparoscopic excision is a safe and effective approach for the pediatric population.

Putting residents in the office: an effective method to teach the systems-based practice competency.

OBJECTIVES: Systems-based practice (SBP) was 1 of 6 core competencies established by the Accreditation Council for Graduate Medical Education and has proven to be one of the most difficult to effectively implement. This pilot study presents an immersion workshop as an effective tool to teach the SBP competency in a way that could easily be integrated into a residency curriculum. DESIGN: In 2006, 16 surgical residents rotated through 3 stations for 30 minutes each: coding and billing, scheduling operations and return appointments, and patient check-in. Participants were administered a pretest and posttest questionnaire evaluating their knowledge of SBP, and were asked to evaluate the workshop. SETTING: Outpatient clinic at MedStar Georgetown University Hospital, Washington, DC. PARTICIPANTS: Residents in the general surgery residency training program at MedStar Georgetown University Hospital. RESULTS: Most residents (62.5%) improved their score after the workshop, whereas 31.25% showed no change and 6.25% demonstrated a decrease in score. Overall within their training levels, all groups demonstrated an increase in mean test score. Postgraduate year-2 residents demonstrated the greatest change in mean score (20%), whereas postgraduate year-4 residents demonstrated the smallest change in mean score (3.3%). CONCLUSIONS: An immersion workshop where general surgery residents gained direct exposure to SBP concepts in situ was an effective and practical method of integrating this core competency into the residency curriculum. Such a workshop could complement more formal didactic teaching and be easily incorporated into the curriculum. For example, this workshop could be integrated into the ambulatory care requirement that each resident must fulfill as part of their clinical training.

A case of small intestinal cast causing SBO in complicated intestinal graft-versus-host disease.

We report an unusual case of small bowel obstruction caused by an intestinal cast in an 8-year-old female who developed intestinal graft-versus-host disease (GVHD) following two unrelated bone marrow transplants for aplastic anemia, and highlight the pathophysiology, common presentations, and surgical complications of intestinal GVHD from the surgeons' perspective.

Laparoscopic drainage of postappendectomy- retained fecalith and intra-abdominal abscess in the pediatric population.

Retained fecalith after an appendectomy is an uncommon complication frequently associated with intra-abdominal abscess. Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. Laparoscopy offers the advantages of enhanced visualization of the abdomen, improved cosmesis, and a quicker return to normal daily activities. The principles of laparoscopic treatment include the careful identification of all anatomic landmarks, as the abscesses are frequently adherent to intra-abdominal structures compromising the safety of the operation. In this paper, we present 2 cases of laparoscopic drainage of an intra-abdominal abscess with retrieval of a fecalith in pediatric patients 1 and 6 weeks after an initial appendectomy and a review the literature.

Forceful evacuation of retained pneumoperitoneum mimics an acute recurrent inguinal hernia.

BACKGROUND: Laparoscopic exploration of the contralateral side during inguinal herniorrhaphy in infants is becoming popular. We present an unusual complication of this technique, namely forceful evacuation of retained pneumoperitoneum mimicking an acute recurrent hernia. METHODS: A 9-month-old female presented for right inguinal herniorrhaphy. Laparoscopic exploration of the left side revealed a closed left internal ring. The pneumoperitoneum was evacuated. The hernia sac had started to tear so it was closed with a running horizontal mattress suture instead of a double ligature after twisting. The internal ring was closed. Upon emergence from anesthesia, the right groin was filled with a mass that we felt was subcutaneous emphysema from evacuation of residual pneumoperitoneum. But to rule out an acute recurrent hernia, we re-explored the groin. There was a large collection of air that had dissected in the subcutaneous tissues and under Scarpa's fascia. The hernia repair was intact. Follow-up 6 months after the repair showed no evidence of a recurrence. RESULTS: This is the first report of an unusual complication of laparoscopic exploration of the contralateral side during hernia repair. Two factors contributed to it. The sac closure was a running mattress suture, which is not as airtight as a double ligature after twisting. The second is the incomplete evacuation of the pneumoperitoneum. CONCLUSION: With the increasing use of laparoscopic contralateral exploration, this case illustrates the need to evacuate the pneumoperitoneum as thoroughly as possible and to consider an airtight closure of the sac.