Occult major venous injury in penetrating thigh trauma: An underdiagnosed cause of morbidity and mortality.

Background: There are no current consensus guidelines that address screening patients who may have occult major venous injury in the setting of penetrating thigh trauma. Yet, such injuries confer significant morbidity and mortality to trauma patients if left untreated. Methods: This paper examines the cases of three patients who presented to our single level I trauma center after sustaining penetrating thigh trauma with negative CT arteriography, all of whom were eventually diagnosed with occult major venous injury. Results: One patient developed massive pulmonary embolism with death and the other two patients required operative exploration due to a foreign body within a major vein and major venous hemorrhage. Conclusion: These cases underscore the importance of having a high index of suspicion for occult major venous injury in select patients with penetrating thigh trauma and negative CT arteriography. Level of evidence: V Study type: therapeutic/care management.

A Novel Strategy to Manage Below-Knee-Amputation (BKA) Stump Complications for Early Wound Healing and BKA Salvage.

INTRODUCTION: The optimal management of major stump complications (operative infection or dehiscence) following below-knee-amputation (BKA) is unknown. We evaluated a novel operative strategy to aggressively treat major stump complications hypothesizing it would improve our rate of BKA salvage. METHODS: Retrospective review of patients requiring operative intervention for BKA stump complications between 2015 and 2021. A novel strategy employing staged operative debridement for source control, negative pressure wound therapy, and reformalization was compared to standard care (less structured operative source control or above knee amputation). RESULTS: 32 patients were studied, 29 of which were male (90.6%) with an average age of 56.1 ± 9.6 y. 30 (93.8%) had diabetes and 11 (34.4%) peripheral arterial disease (PAD). The novel strategy was used in 13 patients and 19 had standard care. Novel strategy patients had higher BKA salvage rates, 100% vs 73.7% (P = .064), and postoperative ambulatory status, 84.6% vs 57.9% (P = .141). Importantly, none of the patients undergoing the novel therapy had PAD, while all progressing to above-knee amputation (AKA) did. To better assess the efficacy of the novel technique, patients progressing to AKA were excluded. Patients undergoing novel therapy who had their BKA level salvaged (n = 13) were compared to usual care (n = 14). The novel therapy's time to prosthetic referral was 72.8 ± 53.7 days vs 247 ± 121.6 days (P < .001), but they did undergo more operations (4.3 ± 2.0 vs 1.9 ± 1.1, P < .001). CONCLUSION: Utilization of a novel operative strategy for BKA stump complications is effective in salvaging BKAs, particularly for patients without PAD.

Faculty Scoring of General Surgery Residency Interviewees: A Comparison of In-Person and Virtual Interview Formats.

OBJECTIVE: With new rules regarding social distancing and non-essential travel bans, we sought to determine if faculty scoring of general surgery applicants would differ between the in-person interview (IPI) and virtual interview (VI) platforms. DESIGN: A single institution, retrospective review comparing faculty evaluation scores of applicant interviewees in the 2019 and 2020 MATCH® application cycles (IPIs) and the 2021 and 2022 application cycle (VIs) was conducted. Faculty scored applicants using a 5-point Likert scale in 7 areas of assessment and assigned each student to 1 of 4 tiers (tier 1 highest). A composite score for the 7 assessments (maximum score 35) was calculated. Mean and composite scores and tiers were compared between VI and IPI cycles and adjusted for within-interviewer correlations. The variance of the 2 groups were also compared. SETTING: Harbor-UCLA Medical Center, an academic, tertiary care hospital. PARTICIPANTS: General Surgery applicants for the 2019 to 2022 MATCH® application cycles. RESULTS: Four hundred forty-one faculty IPI ratings of General Surgery applicants were compared to 531VI ratings. No difference in mean composite scores, individual assessments, or tier ranking. Less variance was identified in the VI group for academic credentials (0.6 vs 0.6, p = 0.01), strength of letters (0.7 vs 0.4, p = 0.005), communication skills (0.4 vs 0.6, p = 0.01), personal qualities (0.2 vs 0.5, p = 0.02), overall sense of fit for program (0.6 vs 0.9, p = 0.01), and tier ranking (0.3 vs 0.4, p = 0.004). CONCLUSIONS: Faculty ratings of General Surgery applicants in the VI format appear to be similar to IPI. However, faculty ratings of VI applicants demonstrated less variability in scores in most assessments. This finding is potentially concerning, as it may suggest an inability of VI to detect subtle differences between applicants as comparted to IPI.

Characteristics Associated With Outstanding General Surgery Residency Graduate Performance, as Rated by Surgical Educators.

Importance: Characteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education. Objective: To determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident. Design, Setting, and Participants: The multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores. Main Outcome and Measures: Surgical educators' rankings of general surgery residency graduates' overall performance. Results: Fifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P < .001), leadership (r = 0.726; P < .001), postoperative clinical skills (r = 0.715; P < .001), and preoperative clinical skills (r = 0.707; P < .001). The remainder of the characteristics were moderately associated with overall performance. The LASSO regression model identified 3 characteristics from which overall resident performance could be accurately predicted without measuring other qualities: surgical judgment (odds ratio [OR] per 1 level of 5-level Likert scale OR, 1.27; 95% CI, 1.03-1.51), leadership (OR, 1.27; 95% CI, 1.06-1.48), and medical knowledge (OR, 1.16; 95% CI, 1.01-1.33). Conclusions and Relevance: All individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

Should Robotic Surgery Training Become a General Surgery Residency Requirement? A National Survey of Program Directors in Surgery.

OBJECTIVE: Robotic-assisted surgery (RAS) accounts for 15% of general surgery (GS) operations performed and is set to grow in prevalence. Currently, there are no training requirements or standard robotic curricula for GS residents. This study aimed to query GS program directors (PDs) on the necessity, extent, and potential impact of including RAS as a required component of residency training. DESIGN: Analysis of responses to a 14-question web-based survey. SETTING: Survey was distributed to PDs via the Association of Program Directors in Surgery listserv in April and May 2021. PARTICIPANTS: General surgery program directors RESULTS: Among 140 respondents, 110 (78.6%) agreed that operating at the robotic console should be a GS residency requirement, yet 93 (66.4%) indicated that RAS exposure negatively impacts the acquisition of other necessary skills. Still, 116 (82.9%) agreed that RAS training provided a net benefit to GS residents, PDs at academic programs were more supportive than those at independent programs of RAS console training requirements (68.2% versus 46.7%, p = 0.048). The median response to the ideal proportion of abdominopelvic cases performed by graduation was 20% robotic, 40% laparoscopic, and 35% open. The suggested minimum number of robotic cases that should be performed by graduation was indicated to be 30 cases by 26% of respondents, 20 by 23%, 10 by 12%, 5 by 4%, and "no minimum" by 36%. CONCLUSIONS: There is strong interest among PDs to institute RAS training requirements for GS residents. This study provides PD perspectives to help inform national conversations on whether and to what extent RAS requirements should be included in GS residency training.

Outcomes of Highest Grade (IV and V) Liver Injuries in Blunt and Penetrating Trauma.

BACKGROUND: High-grade hepatic trauma can be devastating, with complications being common if patients survive. Studies comparing outcome differences between blunt and penetrating mechanism are lacking. This study aimed to describe and evaluate the association of traumatic mechanism with complications in patients sustaining grades IV and V liver injuries. METHODS: A retrospective review of all adults who suffered grades IV and V liver injury from 2015-2020 was performed at a level I trauma center in an urban area. Outcomes in patients with blunt and penetrating mechanisms were compared. RESULTS: A total of 103 patients were included, of which 44 (43%) were penetrating and the remainder blunt. Patients with penetrating injuries were younger, more often male, and more likely to undergo initial operative management (82% vs 40%, P < .001). Regardless of mechanism, high grade liver injuries had similar rates of complications, including bile leak (17% vs 23%, P = .559) and intrabdominal abscess (7% vs 16%, P = .239), and similar need for endoscopic retrograde cholangiopancreatography (12% vs 19%, P = .379). Penetrating injuries required more re-interventions (42% vs 19%, P = .033), specifically more percutaneous drainage procedures (36% vs 12%, P = .016). Overall mortality was 29% and did not differ by mechanism. DISCUSSION: Morbidity and mortality are high for grades IV and V liver injuries. Penetrating high-grade hepatic injuries are more likely to be managed operatively, but mortality and overall complications are similar to blunt mechanisms. This may allow for uniform algorithms to define management strategies regardless of mechanism.

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume. Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume. Design, Setting, and Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations. Main Outcome and Measures: Total major cases performed by each resident during the first 4 months of the pandemic. Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03). Conclusions and Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.

Trauma patients returning to the emergency department after discharge.

BACKGROUND: While readmission rates of trauma patients are well described, little has been reported on rates of re-presentation to the emergency department (ED) after discharge. This study aimed to determine rates and contributing factors of re-presentation of trauma patients to the ED. METHODS: One-year retrospective analysis of discharged adult trauma patients at a county-funded safety-net level one trauma center. RESULTS: Of 1416 trauma patients, 195 (13.8%) re-presented to the ED within 30 days. Of those that re-presented, 47 (24.1%) were re-admitted (3.3% overall). The most common reasons for re-presentation were pain control and wound complications. Patients with Medicare (AOR 2.6, 95% CI 1.3 to 5.2) or other government insurance (AOR 2.5, 95% CI 1.6 to 4.1) were more likely to re-present than patients with private insurance. CONCLUSION: A considerable number of trauma patients re-presented to the ED after discharge for reasons that did not require hospitalization. Discharge planning for certain vulnerable groups should emphasize wound care, pain control and scheduled follow-up to decrease the reliance on the ED.

Should Robotic Surgery Training Be Prioritized in General Surgery Residency? A Survey of Fellowship Program Director Perspectives.

OBJECTIVE: Robotic surgery has been increasingly incorporated into the subspecialties of colorectal (CRS), minimally invasive/bariatric (MIS/Bar), and surgical oncology/hepatobiliary (SO/HPB) surgery, yet its impact on fellowship applicant evaluation and contribution to postresidency training remains undefined. The aim of our study was to evaluate how robotic training during General Surgery (GS) residency affects an applicant's competitiveness from the perspective of fellowship programs. DESIGN: A web-based survey was sent to all 235 accredited fellowship programs in CRS (n = 66), MIS/Bar (n = 122), and SO/HPB (n = 47) within the United States and Canada. Fellowship programs were queried on the import of robotic surgery training during GS residency and its impact on an applicant's match potential. RESULTS: Of 235 programs, 155 (66%) responded to the survey - 42 (63.6%) CRS, 87 (71.3%) MIS/Bar, and 26 (55.3%) SO/HPB. Of responding programs, 147 (94.8%) have a surgical robot at their institution, and 131 (84.5%) have fellows actively operating at the console. Overall, 107 (69%) fellowship program directors rated robotic training during surgery residency as "somewhat" or "very" important for residents seeking fellowship. While 95 (61.3%) programs said GS residents should not prioritize robotic training, 60 (38.7%) felt they should, and 38 (24.5%) were more likely to rank an applicant higher if they had some console exposure. Still, 69.7% (n = 108) of programs expect no robotic experience for incoming fellows. CONCLUSIONS: This study demonstrates that most fellowship programs have low expectations of robotic experience for incoming fellows. Still, it is notable that nearly a quarter of programs would rank an applicant more highly if they had robotic console exposure. While these findings appear reassuring to residents with limited access to robotic training, residency programs should be alerted to the growing importance of robotic exposure.

Primary Skin Closure after Repair of Hollow Viscus Injuries.

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.

Laparoscopic Cholecystectomy Is Safe in Emergency General Surgery Patients with Cirrhosis.

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.

Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection.

Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.

Narrowed pulse pressure predicts massive transfusion and emergent operative intervention following penetrating trauma.

INTRODUCTION: The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS: In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS: There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS: A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.

Investigating Gender Differences in Faculty Evaluations by Trainees in a Gender-Balanced General Surgery Program.

PURPOSE: Women account for 21% of faculty positions in general surgery. In fields with lower female representation, female faculty receive lower evaluation scores by trainees compared to male faculty. At 42%, the female faculty representation in our general surgery department doubles the national average. We sought to determine if variations in faculty evaluations would be observed in a more gender-balanced general surgery program. METHODS: Two years of faculty teaching evaluations by residents in a general surgery residency program were collected from the MedHub system. Total 3277 resident evaluations of 26 faculty members (11 female, 15 male) were analyzed. Seven areas (scored 1-7, with 1 = needs improvement and 7 = outstanding) were examined. Chi-square test was used to compare the percentage of male and female faculty members who scored a 6 or 7 in each category, and multivariate logistic regression analysis was used to determine the association of gender with the evaluation score, while adjusting for the number of encounters between the trainee and the faculty member. RESULTS: There were no significant differences between male and female faculty in the "overall" evaluation score, nor in the "practice-based learning" and the "interpersonal and communication skills" categories. Female faculty had statistically significantly higher scores in "patient care", "professionalism," and "systems-based care" categories, whereas male faculty had higher evaluations in the "medical knowledge" category. CONCLUSION: In a general surgery residency program with a relatively gender-balanced faculty, there was no gender difference in the "overall" evaluation of faculty by residents. However, there were gender differences in specific domains. These findings suggest that gender balance in teaching faculty may help eliminate previously observed teaching evaluation bias in the traditionally male dominated fields.

Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents.

Importance: In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts. Objective: To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers. Design, Setting, and Participants: This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017. Main Outcomes and Measures: Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level. Results: A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research. Conclusions and Relevance: This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection.

BACKGROUND: Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. METHODS: We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. RESULTS: Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. CONCLUSIONS: Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

A survey of robotic surgery training curricula in general surgery residency programs: How close are we to a standardized curriculum?

BACKGROUND: Robotic surgery is increasingly adopted into surgical practice, but it remains unclear what level of robotic training general surgery residents receive. The purpose of our study was to assess the variation in robotic surgery training amongst general surgery residency programs in the United States. METHODS: A web-based survey was sent to 277 general surgery residency programs to determine characteristics of resident experience and training in robotic surgery. RESULTS: A total of 114 (41%) programs responded. 92% (n = 105) have residents participating in robotic surgeries; 68%(n = 71) of which have a robotics curriculum, 44%(n = 46) track residents' robotic experience, and 55%(n = 58) offer formal recognition of training completion. Responses from university-affiliated (n = 83) and independent (n = 31) programs were not significantly different. CONCLUSIONS: Many general surgery residencies offer robotic surgery experience, but vary widely in requisite components, formal credentialing, and case tracking. There is a need to adopt a standardized training curriculum and document resident competency.