Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

OBJECTIVE: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

Improving first case start times using Lean in an academic medical center.

BACKGROUND: Lean is a process improvement strategy that can improve efficiency of the perioperative process. The purpose of this study was to identify etiologies of late surgery start times, implement Lean interventions, and analyze their effects. METHODS: A retrospective review of all first-start surgery cases was performed. Lean was implemented in May 2015, and cases 7 months before and after implementation were analyzed. RESULTS: A total of 4,492 first-start cases were included; 2,181 were pre-Lean and 2,311 were post-Lean. The post-Lean group had significantly higher on-time starts than the pre-Lean group (69.0% vs 57.0%, P < .01). The most common delay etiology was surgeon-related for both groups. Delayed post-Lean cases were significantly less likely to be due to preoperative assessment (14.9% vs 9.9%, P < .01) and more likely due to patient-related (16.5% vs 22.3%, P < .01) or chaplain (1.8% vs 4.0%, P < .01) factors. Delayed starts occurred more often on snowy and cold days, and less often on didactic days (P < .01). CONCLUSIONS: Modifying preoperative tasks using Lean methods can improve operating room efficiency and increase on-time starts.

The use of blunt-tipped 12-mm trocars without fascial closure in laparoscopic live donor nephrectomy.

OBJECTIVES: Blunt-tipped trocar placement may eliminate the need for fascial closure in transperitoneal laparoscopic live donor nephrectomies (LDN). The process of 12-mm blunt-tipped trocar insertion through the abdominal wall involves fascial and muscle spreading, not incision. Coaptation of the tissue layers occurs during withdrawal of the trocar, preventing volume gaps that can be prone to herniation. METHODS: We retrospectively assessed the safety and efficacy of fascial nonclosure after 12-mm blunt-tipped port insertion in 70 transperitoneal LDNs performed between October 1998 and March 2001. Five ports (two 12-mm blunt-tipped and three 5-mm blunt-tipped) were used in all cases. The 12-mm trocars were inserted at the lateral border of the rectus muscle, approximately 8 cm below the costal margin and also along the anterior axillary line approximately 8 cm below the costal margin. Fascial non-closure was performed in all 70 patients. Postoperative data were analyzed regarding complications and long-term outcomes. RESULTS: Three major and 7 minor complications occurred in this series. No patient developed clinically detectable trocar-site hernias or other complications related to blunt-trocar placement. CONCLUSIONS: Our data shows that fascial nonclosure after transperitoneal 12-mm blunt-tipped trocar insertion is safe. Visualization of the tissue layers during port placement facilitated the insertion process. Further application of this method in a larger number of patients is needed to confirm its clinical applicability.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience.

PURPOSE: We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions. MATERIALS AND METHODS: We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures. RESULTS: Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions). CONCLUSIONS: Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.

One versus two proficient laparoscopic surgeons for laparoscopic live donor nephrectomy.

OBJECTIVES: To compare the laparoscopic donor nephrectomy (LDN) results obtained by two different surgical teams, one consisting of a proficient laparoscopic surgeon assisted by an inexperienced laparoscopic surgeon and another consisting of two proficient laparoscopic surgeons. With more centers embarking on LDN programs, it is important to identify the factors that can improve overall outcomes during the initial learning curve. METHODS: A retrospective review was performed of the initial 70 sequential LDNs performed between October 1998 and March 2001 at our institutions. The procedures were stratified into two groups. Group 1 consisted of LDN cases performed by one proficient laparoscopic surgeon and an inexperienced laparoscopic surgeon (resident, fellow, or faculty) as the first assistant; group 2 consisted of cases performed by two proficient laparoscopic surgeons. RESULTS: Twenty-six LDNs were performed by group 1 and 44 by group 2. The total operative time and estimated blood loss showed a statistically significant decrease in group 2 compared with group 1, 143 +/- 32 minutes versus 218 +/- 38 minutes (P <0.001) and 92 +/- 115 mL versus 158 +/- 148 mL (P = 0.044), respectively. Two major complications occurred in group 1 (7.7%) and two major complications occurred in group 2 (4.5%). The 3-month postoperative recipient creatinine levels were similar for both groups, 1.6 +/- 1.3 versus 1.4 +/- 0.4 (P = 0.408). CONCLUSIONS: A surgical team composed of two proficient laparoscopic surgeons during the early learning curve of LDN may allow safe and efficient development of a laparoscopic live donor renal transplantation program.

Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy.

PURPOSE: We present a novel method of kidney retrieval based on a modified Pfannenstiel incision and insertion of the assistant hand into the abdominal cavity without a device for pneumoperitoneum preservation. This maneuver is performed as the last step in pure laparoscopic live donor nephrectomy. Also, we assessed the effect of this technique on warm ischemia time compared with the standard laparoscopic bag retrieval technique. MATERIALS AND METHODS: A total of 70 laparoscopic live donor nephrectomies were performed at our institutions between October 1998 and March 2001. The first 43 cases were completed using an EndoCatch bag device (Auto Suture, Norwalk, Connecticut) for specimen retrieval, while the last 27 were done using a novel manual retrieval technique through a modified Pfannenstiel incision. We retrospectively analyzed the results in regard to warm ischemia time and intraoperative complications related to the procedure. RESULTS: A statistically significant difference was noted in the EndoCatch and manual retrieval groups in regard to warm ischemia time (p <0.001). There were 2 complications related to the EndoCatch device and none related to the manual technique. No differences were detected regarding recipient outcomes. CONCLUSIONS: Manual specimen retrieval after live donor nephrectomy allows shorter warm ischemia time, while saving the cost of an EndoCatch bag or pneumoperitoneum preserving device that would be used during hand assisted live donor nephrectomy. It was shown to be a safe method without increased donor morbidity.

Transperitoneal laparoscopic renal surgery using blunt 12-mm trocar without fascial closure.

BACKGROUND AND PURPOSE: Conical blunt trocar insertion may eliminate the need for fascial closure (FC) in transperitoneal laparoscopic renal surgery. This concept applies to 12-mm blunt trocar placement through muscular parts of the abdominal wall, relying on muscle splitting and eventual muscle retraction when the trocar is removed. We retrospectively assessed the safety of fascial nonclosure (FNC) after 12-mm blunt port insertion. PATIENTS AND METHODS: Ninety transperitoneal laparoscopic renal procedures were performed between August 1999 and May 2000. Four ports (two 12 mm and two 5 mm) were usually used except for 30 donor nephrectomies, where an additional 5-mm port was used. The 12-mm trocars were inserted at the lateral border of the rectus muscle 5 cm below the costal margin and in the anterior axillary line 8 cm below the costal margin. Fascial closure was performed in 62 patients and nonclosure in 28 patients. Exclusion criteria for FNC included midline location, malnutrition, renal failure, and chronic use of steroids. Postoperative outcomes were compared in 20 patients with FNC matched with 20 patients with FC. RESULTS: At an average of 4.8 months of follow-up, none of the patients developed a trocar site hernia. No significant statistical differences were observed between the groups with regard to intraoperative and postoperative data. CONCLUSIONS: These two approaches appear to be equivalent in terms of patient morbidity and postoperative hospital stay. Fascial nonclosure after transperitoneal 12-mm blunt trocar insertion, through muscular parts of the abdominal wall may be safe and efficacious and eliminates the last step in transperitoneal laparoscopic renal surgery.

Comparison of laparoscopic live donor nephrectomy versus the traditional open technique.

OBJECTIVES: Laparoscopic live donor nephrectomy (LDN) is a minimally invasive technique for kidney procurement that may decrease the donor disincentives. In addition, recent studies have demonstrated that LDN has equal graft and recipient survival when compared to the standard open approach. We report our experience with LDN and compare the results with the most recent open donor nephrectomy (ODN) group performed at our institutions. MATERIAL AND METHODS: The records of 70 consecutives left sided LDN performed between October 1998 and March 2001 were retrospectively reviewed and compared to 40 ODN performed between April 1996 and January 2000. RESULTS: Average blood loss (127 ml vs. 317 ml; p < 0.001), time to PO intake (25 hrs vs. 34.6 hrs; p < 0.001), and hospital stay (2.7 d vs. 4.2 d; p < 0.001) were statistically significant better for the LDN group when compared to ODN group. The average warm ischemia time in the LDN group was 138 seconds (range 55 - 360). The major complication rate in both laparoscopic (4 cases) and open (2 cases) donor groups was similar (5.7% and 5%, respectively). The average post-operative day (POD) 90 recipient creatinine was similar for both groups (1.5+/-0.9 vs. 1.5+/-0.8 ng/dL; p= 0.799). Similar rates of recipient ureteral complications occurred in the LDN and ODN groups: 1.4% (1 case) and 2.5% (1 case), respectively. Likewise, acute rejection was also similar at 22.8% (16 cases) and 27.5% (11 cases) in the LDN and ODN respectively. CONCLUSIONS: At our institutions, LDN was superior to ODN with regards to donor operative blood loss, time to PO intake, and length of hospital stay. In addition, similar complication rates, and 3-month recipient kidney function were demonstrated.