An approach to achieve tension-free closure and mitigate recurrence in the management of recurrent cervical keloids.

Keloid is a burdensome condition that negatively affects patient's quality of life. It is influenced by a spectrum of risk factors, including tension. We propose an approach to address the tension-free closure and optimize surgical outcomes in neck keloid. A retrospective review of neck keloid patients who underwent surgical treatment between 2014 and 2022 was performed. Five patients underwent surgical interventions. Two patients had sufficient and three had insufficient tissue redundancy. The former underwent keloid excision with tension-free closure. The latter underwent keloid excision with full thickness skin graft for tension-free closure. One patient required re-excision with free flap coverage. All patients received postoperative low dose radiation. All patients were satisfied with the results and there were no signs of keloid recurrence during the follow-up period. Tension during closure following keloid excision is a modifiable risk factor. An appropriate algorithm providing tension-free closure can minimize the recurrence.

Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study.

OBJECTIVE: The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents. METHODS: From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts. RESULTS: A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed. CONCLUSIONS: RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.

Surgery Website as a 24/7 Adjunct to a Surgical Curriculum.

OBJECTIVE: Successfully teaching duty hour restricted trainees demands engaging learning opportunities. Our surgical educational website and its associated assets were assessed to understand how such a resource was being used. DESIGN: Our website was accessible to all Mayo Clinic employees via the internal web network. Website access data from April 2015 through October 2016 were retrospectively collected using Piwik. SETTING: Academic, tertiary care referral center with a large general surgery training program. Mayo Clinic, Rochester, MN. PARTICIPANTS: A total of 257 Mayo Clinic employees used the website. RESULTS: The website had 48,794 views from 6313 visits by 257 users who spent an average of 14 ± 11 minutes on the website. Our website houses 295 videos, 51 interactive modules, 14 educational documents, and 7 flashcard tutorials. The most popular content type was videos, with a total of 30,864 views. The most popular visiting time of the day was between 8 pm and 9 pm with 6358 views (13%), and Thursday was the most popular day with 17,907 views (37%).  A total of 78% of users accessed content beyond the homepage. Average visits peaked in relation to 2 components of our curriculum: a 240% increase one day before our biannual intern simulation assessments, and a 61% increase one day before our weekly conducted Friday simulation sessions. Interns who rotated on the service of the staff surgeon who actively endorses the website had 93% more actions per visit as compared to other users. The highest clicks were on the home banner for our weekly simulation session pre-emptive videos, followed by "groin anatomy," and "TEP hernia repair" videos. CONCLUSIONS: Our website acted as a "just-in-time" accessible portal to reliable surgical information. It supplemented the time sensitive educational needs of our learners by serving as a heavily used adjunct to 3 components of our surgical education curriculum: weekly simulation sessions, biannual assessments, and clinical rotations.

Accurate surgical skills evaluation: Does it mandate raters have a medical background?

BACKGROUND: Surgeons rarely have time to assess/rate trainee performance. From a 10 year-experience of implementing OSCE style assessments, we hypothesize that the accurate scoring of interns in selected tests is not affected by the rater's medical background. METHODS: A prospective collection of quantitative scoring data by both medical school graduates and college students was compared. Each rater underwent training and then watched three videos of actors performing in each of two OSCE stations and individually scored them. RESULTS: Twelve college students and 16 medical graduates participated. There was no difference in the mean scores between rating groups for chest tube insertion (Video 1: 1.7 vs. 2.0; Video 2: 2.9 vs 3.1; Video 3: 6.1 vs 6.1; p = 0.8) and cricothyrotomy (Video 1: 4.0 vs 4.5; Video 2: 4.8 vs 5.1; Video 3: 9.2 vs 9.1; p = 0.7). CONCLUSION: Accurate scoring of surgical performance does not mandate a medical background. Given the limited availability of attending surgeons for assessments, use of validated, simple checklists can help raters with minimal medical experience perform assessments proficiently.

At Home Preresidency Preparation for General Surgery Internship: A Pilot Study.

OBJECTIVE: To create a novel "at-home" preresidency preparatory adjunct for medical students entering surgical residency. DESIGN: Preparatory resources were mailed to match medical students before residency matriculation in 2015. This included "how-to" videos, low-cost models, and surgical instruments for 5 "stations" (arterial blood gas analysis, anatomy and imaging knowledge, knot tying ability, and suturing dexterity) of our program's biannual general surgery intern objective assessment activity (Surgical Olympics: total 13 stations, 10 points each). Scores from 2015 were compared with 2014 historical controls in a retrospective manner using the Student's t-test. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: Postgraduate year 1 general surgery trainees (interns) from the years 2014 and 2015. RESULTS: Twenty-six interns participated in the 2015 assessment and were compared to thirty-two 2014 interns. Overall mean scores were low, but higher (19.7 vs. 15.4, p = 0.04) in the 2015 class. The largest increase was noted in the anatomy knowledge station (mean = 5.0 vs. 1.9, p < 0.01). Scores in stations assessing technical competence were similar to controls. The number of perfect scores among the 5 stations was higher (10 vs. 5) in the 2015 group. Mean scores from the other 8 stations, for which no resources were mailed, showed no difference (29.3 vs. 28.3, p = 0.75). CONCLUSIONS: Enacting a simple, home-based curriculum for medical students before surgical residency, improved performance on early knowledge assessments.

Does scripting operative plans in advance lead to better preparedness of trainees? A pilot study.

BACKGROUND: We pondered if preoperative scripting might better prepare residents for the operating room (OR). METHODS: Interns rotating on a general surgeon's service were instructed to script randomized cases prior to entering the OR. Scripts contained up to 20 points highlighting patient information perceived important for surgical management. The attending was blinded to the scripting process and completed a feedback sheet (Likert scale) following each procedure. Feedback questions were categorized into "preparedness" (aware of patient specific details, etc.) and "performance" (provided better assistance, etc.). RESULTS: Eight surgical interns completed 55 scripted and 61 non-scripted cases. Total scores were higher in scripted cases (p = 0.02). Performance scores were higher for scripted cases (3.31 versus 3.13, p = 0.007), while preparedness did not differ (3.65 and 3.62, p = 0.51). CONCLUSIONS: This pilot study suggests scripting cases may be a useful preoperative planning tool to increase interns' operative and patient care performance but may not affect perceived preparedness.