Current Barriers in Robotic Surgery Training for General Surgery Residents.

OBJECTIVE: To assess the current barriers in robotic surgery training for general surgery residents. DESIGN: Multi-institutional web-based survey. SETTING: 9 academic medical centers with a general surgery residency. PARTICIPANTS: General surgery residents of at least PGY-3 training level. RESULTS: 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console. CONCLUSIONS: General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

Nonoperative fracture treatment in the modern era.

BACKGROUND: Nonoperative fracture treatment has been used for millennia, but there has been no demographic study of its use for half a century. In the last 50 to 60 years, there has been an increased interest in operative fracture fixation and in many specialized Trauma hospitals nonoperative management is less frequently used. However, these specialized hospitals do not reflect fracture treatment in the whole community, and we have undertaken a study to investigate the current prevalence of nonoperative fracture treatment. METHODS: A retrospective analysis of 7,863 consecutive fractures in a defined population was undertaken. The use of nonoperative management in different fractures was assessed as was the influence of fracture severity, mode of injury, multiple fractures and social deprivation in the choice of treatment. A comparison of current treatment with that of the 1940s and 1950s was undertaken. RESULTS: The prevalence of nonoperative treatment was 74.6% with 91.6% of children and 67.6% of adults being treated nonoperatively. There were significant differences in upper and lower limb fractures in both children and adults. The major determinant of nonoperative management was age, although the severity of fracture, mode of injury, and presence of multiple fractures were also important. Social deprivation was not a significant factor except in adult metacarpal fractures. CONCLUSIONS: Nonoperative treatment remains the most widely used method of fracture management. Its prevalence decreases with age, particularly in lower limb fractures. In children, there is a bimodal operative treatment distribution and an increasing prevalence of operative treatment. In some adult fractures, the prevalence of surgery is increasing, but in others, we operate no more frequently than in the 1950s, despite improved operative techniques.

Epidemiology of adult fractures: A review.

The epidemiology of adult fractures is changing quickly. An analysis of 5953 fractures reviewed in a single orthopaedic trauma unit in 2000 showed that there are eight different fracture distribution curves into which all fractures can be placed. Only two fracture curves involve predominantly young patients; the other six show an increased incidence of fractures in older patients. It is popularly assumed that osteoporotic fractures are mainly seen in the thoracolumbar spine, proximal femur, proximal humerus and distal radius, but analysis of the data indicates that 14 different fractures should now be considered to be potentially osteoporotic. About 30% of fractures in men, 66% of fractures in women and 70% of inpatient fractures are potentially osteoporotic.

Sudden onset of vomiting as a presentation of perimesencephalic subarachnoid haemorrhage.

Subarachnoid haemorrhage (SAH) makes up 1% of all attendances for acute severe headache to emergency departments, but other less common presentations may be seen. A 28-year-old man presented to the ED complaining of a 24-h history of nausea and vomiting of sudden onset, but without headache. The patient also described mild photophobia and neck stiffness. A computed tomography scan revealed perimesencephalic blood, and a subsequent angiogram was negative. This appearance is seen in cases of non-aneurysmal SAH, which often occur in younger, male, normotensive patients, and give rise to few warning symptoms. A high index of suspicion should be maintained for SAH, even in the absence of headache.