Comparison of Kinect and Leap Motion for Intraoperative Image Interaction.

Background. Touchless interaction devices have increasingly garnered attention for intraoperative imaging interaction, but there are limited recommendations on which touchless interaction mechanisms should be implemented in the operating room. The objective of this study was to evaluate the efficiency, accuracy, and satisfaction of 2 current touchless interaction mechanisms-hand motion and body motion for intraoperative image interaction. Methods. We used the TedCas plugin for ClearCanvas DICOM viewer to display and manipulate CT images. Ten surgeons performed 5 image interaction tasks-step-through, pan, zoom, circle measure, and line measure-on the 3 input interaction devices-the Microsoft Kinect, the Leap Motion, and a mouse. Results. The Kinect shared similar accuracy with the Leap Motion for most of the tasks. But it had an increased error rate in the step-through task. The Leap Motion led to shorter task completion time than the Kinect and was preferred by the surgeons, especially for the measure tasks. Discussion. Our study suggests that hand tracking devices, such as the Leap Motion, should be used for intraoperative imagining manipulation tasks that require high precision.

Virtual pointer for gaze guidance in laparoscopic surgery.

BACKGROUND: A challenge of laparoscopic surgery is learning how to interpret the indirect view of the operative field. Acquiring professional vision-understanding what to see and which information to attend to, is thereby an essential part of laparoscopic training and one in which trainers exert great effort to convey. We designed a virtual pointer (VP) that enables experts to point or draw free-hand sketches over an intraoperative laparoscopic video for a novice to see. This study aimed to investigate the efficacy of the virtual pointer in guiding novices' gaze patterns. METHODS: We conducted a counter-balanced, within-subject trial to compare the novices' gaze behaviors in laparoscopic training with the virtual pointer compared to a standard training condition, i.e., verbal instruction with un-mediated gestures. In the study, seven trainees performed four simulated laparoscopic tasks guided by an experienced surgeon as the trainer. A Tobii Pro X3-120 eye-tracker was used to capture the trainees' eye movements. The measures include fixation rate, i.e., the frequency of trainees' fixations, saccade amplitude, and fixation concentration, i.e., the closeness of trainees' fixations. RESULTS: No significant difference in fixation rate or saccade amplitude was found between the virtual pointer condition and the standard condition. In the virtual pointer condition, trainees' fixations were more concentrated (p = 0.039) and longer fixations were more clustered, compared to the Standard condition (p = 0.008). CONCLUSIONS: The virtual pointer effectively improved surgical trainees' in-the-moment gaze focus during the laparoscopic training by reducing their gaze dispersion and concentrating their attention on the anatomical target. These results suggest that technologies which support gaze training should be expert-driven and intraoperative to efficiently modify novices' gaze behaviors.

Effects of a Virtual Pointer on Trainees' Cognitive Load and Communication Efficiency in Surgical Training.

We investigated the cognitive load effect of a trainer providing surgical instruction by pointing/drawing over laparoscopic video to a trainee. Results showed that while cognitive load is higher overall with the use of the instructional system, there is a decrease by the second experience of being instructed by the Virtual Pointer. Further analysis showed that trainees were more likely to perform the surgical task and watch/listen to the trainer's instruction at the same time when the instructional system was used. This is thought to be an indication of more efficient communication when using the instructional system. Thus, although there is a small cognitive overload with the instructional system initially, the more efficient communication allows trainees to better integrate the knowledge and instructions being conveyed into the actions they must perform - indicating a better learning environment.

A virtual pointer to support the adoption of professional vision in laparoscopic training.

PURPOSE: To assess a virtual pointer in supporting surgical trainees' development of professional vision in laparoscopic surgery. METHODS: We developed a virtual pointing and telestration system utilizing the Microsoft Kinect movement sensor as an overlay for any imagine system. Training with the application was compared to a standard condition, i.e., verbal instruction with un-mediated gestures, in a laparoscopic training environment. Seven trainees performed four simulated laparoscopic tasks guided by an experienced surgeon as the trainer. Trainee performance was subjectively assessed by the trainee and trainer, and objectively measured by number of errors, time to task completion, and economy of movement. RESULTS: No significant differences in errors and time to task completion were obtained between virtual pointer and standard conditions. Economy of movement in the non-dominant hand was significantly improved when using virtual pointer ([Formula: see text]). The trainers perceived a significant improvement in trainee performance in virtual pointer condition ([Formula: see text]), while the trainees perceived no difference. The trainers' perception of economy of movement was similar between the two conditions in the initial three runs and became significantly improved in virtual pointer condition in the fourth run ([Formula: see text]). CONCLUSIONS: Results show that the virtual pointer system improves the trainer's perception of trainee's performance and this is reflected in the objective performance measures in the third and fourth training runs. The benefit of a virtual pointing and telestration system may be perceived by the trainers early on in training, but this is not evident in objective trainee performance until further mastery has been attained. In addition, the performance improvement of economy of motion specifically shows that the virtual pointer improves the adoption of professional vision- improved ability to see and use laparoscopic video results in more direct instrument movement.

Intraoperative "Micro Breaks" With Targeted Stretching Enhance Surgeon Physical Function and Mental Focus: A Multicenter Cohort Study.

OBJECTIVE: The aim of this study was to investigate the effect of intraoperative targeted stretching micro breaks (TSMBs) on the experienced pain and fatigue, physical functions, and mental focus of surgeons. BACKGROUND: Surgeons are routinely subject to mental and physical stresses through the course of their work in the operating room. One of the factors most contributory to the shortening of a surgeon's career is work-related pain and its effects on patient safety and personal relationships. METHODS: Surgeons and operating room staff from 4 medical centers rated pain/fatigue, physical, and mental performance using validated scales during 2 operative days: 1 day without implementing TSMB, the other including standardized (1.5 to 2 minutes) guided TSMB at appropriate 20 to 40-minute intervals throughout each case. Case type and duration were recorded as were surgeon pain data before and after each procedure and at the end of the surgical day. Individual body part pre/postdiscomfort difference was modeled, controlling for clinical center. Random coefficient mixed models accounted for surgeon variability. RESULTS: Sixty-six participants (69% men, 31% women; mean 47 years) completed 193 "non-TSMB" and 148 "TSMB" procedures. Forty-seven percent of surgeons were concerned that musculoskeletal pain may shorten their career. TSMB improved surgeon postprocedure pain scores in the neck, lower back, shoulders, upper back, wrists/hands, knees, and ankles. Operative duration did not differ (P> 0.05). Improved pain scores with TSMB were statistically equivalent (P > 0.05) for laparoscopic and open procedures. Surgeons perceived improvements in physical performance (57%) and mental focus (38%); 87% of respondents planned to continue TSMB. CONCLUSIONS: Many surgeons are concerned about career-ending or limiting musculoskeletal pain. Intraoperative TSMB may represent a practical, effective means to reduce surgeon pain, enhance performance, and increase mental focus without extending operative time.

Potential Operating Room Fire Hazard of Bone Cement.

Approximately 600 cases of operating room (OR) fires are reported annually. Despite extensive fire safety education and training, complete elimination of OR fires still has not been achieved. Each fire requires an ignition source, a fuel source, and an oxidizer. In this case report, we describe the potential fire hazard of bone cement in the OR. A total knee arthroplasty was performed with a standard medial parapatellar arthrotomy. Tourniquet control was used. After bone cement was applied to the prepared tibial surface, the surgeon used an electrocautery device to resect residual lateral meniscus tissue-and started a fire in the operative field. The surgeon suffocated the fire with a dry towel and prevented injury to the patient. We performed a PubMed search with a cross-reference search for relevant papers and found no case reports outlining bone cement as a potential fire hazard in the OR. To our knowledge, this is the first case report identifying bone cement as a fire hazard. OR fires related to bone cement can be eliminated by correctly assessing the setting time of the cement and avoiding application sites during electrocautery.

Laparoscopic Subxiphoid Hernia Repair with Intracorporeal Suturing of Mesh to the Diaphragm as a Means to Decrease Recurrence.

BACKGROUND: Subxiphoid hernias are a rare complication of median sternotomy with an incidence of 1%-4.2%. Repair of subxiphoid hernias is technically demanding with recurrence rates of 42% and 30% following open and laparoscopic repairs, respectively. We present a novel approach to the laparoscopic repair of subxiphoid hernias with improved overlap and fixation. MATERIALS AND METHODS: A novel technique for repairing subxiphoid hernias is described. The falciform ligament is dissected superiorly toward the diaphragm to allow proper subfascial positioning of the mesh with adequate overlap. Multiple nonabsorbable intracorporeal sutures are used to anchor the mesh to the diaphragm above the costal margins. Transfascial nonabsorbable sutures and tacks are used to fix the mesh to the anterior abdominal wall below the costal margin. RESULTS: We have used this method in 4 patients with a mean age of 60.5 years and a female to male ratio of 4:0. The average hernia defect size was 20.5 cm(2), and the average duration of operation was 93 minutes. There were no reported postoperative complications or evidence of recurrence at the 1-year follow-up. CONCLUSIONS: Laparoscopic repair of subxiphoid hernias can be safely accomplished with mesh sutured to the diaphragm for improved overlap and fixation with the goal of reducing recurrence rates.

Porcine acellular dermal matrix (PADM) vascularises after exposure in open necrotic wounds seen after complex hernia repair.

Biological alternatives to synthetic meshes are increasingly utilised in complex abdominal wall reconstruction. There is a lack of evidence demonstrating that non-cross-linked porcine acellular dermal matrix vascularizes and integrates with human tissue in suboptimal wound conditions. We aimed to evaluate these properties in Strattice™ (Life Cell Inc., Branchburg, NJ) following ventral hernia repair. A retrospective review of patients with high-risk ventral hernia repair utilising Strattice™ as an onlay after open component separation was conducted. Patients with postoperative wound exploration and exposure of the onlay were included in this review. One patient underwent punch biopsy for histological analysis. Eleven patients with wound complications necessitating postoperative debridement and exposure of Strattice™ onlay were identified. The onlay was partially debrided in two cases, and one case required complete excision. Vascularisation was clinically evident in 10 of 11 cases (91%) as demonstrated by the presence of granulation tissue and/or the ability to support a skin graft. Histological analysis of one onlay 3 months postoperatively showed neovascularisation and collagen remodelling with minimal inflammatory response. Strattice™ demonstrated resistance to rejection, ability to undergo vascularisation and incorporation into host tissues in sub-optimal wound conditions following ventral hernia repair.

A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia.

BACKGROUND: Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. METHODS: This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. RESULTS: There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. CONCLUSIONS: This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

Pectoralis major turnover versus advancement technique for sternal wound reconstruction.

BACKGROUND: We compared the efficacy of pectoralis turnover versus advancement technique for sternal wound reconstruction. METHODS: A retrospective chart review was performed, December 1989 to December 2010, to compare postoperative complication rates between pectoralis major turnover versus pectoralis major advancement reconstruction techniques. Complications included hematomas, wound infections, tissue necrosis, dehiscence, and need for reoperation. Pearson χ and logistic regression were used and significance was P < 0.05. RESULTS: Sixty-seven patients received 91 tissue flaps. Eleven patients (16%) required reoperation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Four patients (6%) were treated conservatively for minor complications. Overall, complication rates were significantly higher after pectoralis major advancement reconstruction (32.5% vs. 3.7%, P = 0.004). CONCLUSIONS: When feasible, pectoralis major turnover flap offers a superior reconstructive technique for complex sternal wounds, with diminished complications compared with the pectoralis advancement flap.

Prognostication for body contouring surgery after bariatric surgery.

OBJECTIVE: Body contouring surgery has become a steadily increasing part of weight loss treatment in the population of patients electing to undergo bariatric surgery. This study aims to elicit factors that can be used to prognosticate which bariatric surgery patients will choose to undergo body contouring procedures. METHODS: A database of 381 patients who underwent gastric bypass surgery between August 2002 and December 2005 was retrospectively reviewed. All patients with subsequent body contouring surgery (group I) were identified and compared with those without it (group II). Variables studied were age, gender, preoperative excess body weight, percent excess weight loss at 6 and 12 months, preoperative body mass index, and change in body mass index at 6 and 12 months. RESULTS: We identified 24 patients for group I and 168 patients for group II. Group I was significantly younger with a mean age of 36 ± 9 years than group II with a mean age of 41 ± 10 years (P = .023). Change in body mass index was significantly greater in group I with changes of 16.1 ± 4 and 13.82 ± 3 (P = .001) at 6 months and changes of 21.4 ± 6.6 and 17.39 ± 4.6 (P < .0001) at 12 months in group I and group II, respectively. Lastly, the percent excess weight loss at 12 months was significantly greater in group I with a mean percent excess weight loss of 70.1 ± 13.3 than in group II with a mean percent excess weight loss of 62 ± 16.6 (P = .0052). CONCLUSIONS: Age, change in body mass index at 6 and 12 months, and percent excess weight loss at 12 month follow-up were useful predictive factors to determine which bariatric surgery patients ultimately underwent body contouring procedures.

Mental and physical impact of body contouring procedures on post-bariatric surgery patients.

OBJECTIVE: The rapid rate of weight loss following bariatric surgery leads to areas of excessive skin that can cause physical ailments and distortion of body image. Dissatisfaction with the excessive skin can lead patients to seek plastic surgery. This study aims to assess the changes in mental and physical quality of life after body contouring procedures in the post-bariatric surgery population. METHODS: In this cross-sectional study, the 36-Item Short Form Health Survey was given to 104 patients divided into 4 groups consisting of a control group, obese patients, post-bariatric surgery patients, and post-bariatric and -body contouring surgery patients. Scores from each survey question were individually averaged, scaled, and converted to the corresponding 8 scales that make up the 36-Item Short Form Health Survey. Scale comparisons were accomplished by analysis of variance and t test. RESULTS: Compared with the obese group, both post-bariatric surgery patients and post-body contouring surgery patients had improved quality of life. When comparing the post-body contouring and post-bariatric surgery patients, the post-body contouring group did not show significant quality of life improvement and actually scored significantly lower in 2 measures, Role Emotional and Social Functioning, indicating a decreased mental component of quality of life. When compared with the control group, the post-body contouring surgery group had statistically significant lower scores in 6 of the 8 scales. CONCLUSIONS: The functional impairment caused by excessive skin following massive weight loss interferes with quality of life. Patients electing to have body contouring after bariatric surgery show decreased quality of life even after plastic surgery compared to those patients who do not.

Sternal reconstruction after cardiac transplantation: a case of an oversized donor heart.

BACKGROUND: We present a unique case of a cardiac transplant recipient who received an oversized heart. METHODS: To allow the chest to accommodate the organ, extensive resection of the bony chest wall was performed. As both pectoralis major myocutaneous flaps and omental transposition were insufficient to cover the wound, a chest rotational flap was chosen. RESULTS: The large size of the flap allowed us to cover the entire protuberant heart, and the excess soft tissue absorbed the pulsations from the heart without placing tension on the suture line. CONCLUSION: While the closure of complex sternal wounds can pose great challenges, the plastic surgeon possesses a variety of options including pectoralis, omental, rectus abdominus, latissimus dorsi as well as skin and subcutaneous flap closures to choose from.

An effective technique for salvage of cardiac-related devices.

Millions of patients require implantable cardiac devices for management of cardiac dysrhythmias. These devices are susceptible to erosion, exposure, or infection and plastic surgeons are consulted when salvage is required. As of yet, an anterior muscle-splitting approach to effectively and safely relocate the device into the subpectoral position has not been described in the plastic surgery literature. The authors retrospectively reviewed the charts of 7 patients who required repositioning of cardiac devices. Indications for repositioning included exposure, erosion, infection, hematoma at the time of primary placement (3), and one cosmetic revision. All patients were treated with subpectoral repositioning of the device into the subpectoral space via an anterior muscle-splitting approach. Six of 7 patients (86%) achieved successful long-term repositioning in the subpectoral position without recurrent exposure or hematoma and with good cosmetic results. One patient who had a prior history of multiple failed device placements required reoperation due to recurrent infection. The anterior muscle-splitting technique proposed by the authors for defibrillator or pacemaker salvage is a feasible technique with promising results. Plastic surgeons should be aware of this simple and effective approach.

Significant predictors of complications after sternal wound reconstruction: a 21-year experience.

BACKGROUND: We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. METHODS: A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05. RESULTS: In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006). CONCLUSIONS: Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Transoral submucosal resection of the inferior turbinate: a novel approach to functional rhinoplasty.

BACKGROUND: In the presence of turbinate dysfunction, an inferior turbinectomy for persistent hypertrophy of bone and/or mucosa may be performed. We sought to explore anatomic feasibility of a transoral turbinectomy. METHODS: After transoral inferior turbinectomy in 12 cadavers, average distances from the external nasal valve to inferior turbinate and from pyriform aperture to inferior turbinate were compared. Average "area of access" was calculated. Preoperative and postoperative nasal length, tip projection, and alar-base width were also compared. RESULTS: Average distance from external nasal valve to inferior turbinate was 32.4 mm. Average distance from aperture to inferior turbinate was 2.4 mm (P < 0.0001). Average "areas of access" to nasal vault through the external nasal valve and mouth were 183.9 mm(2) and 243.6 mm(2) (P = 0.07), respectively. CONCLUSIONS: The transoral approach provides a larger "area of access" to the turbinate, a statistically significant reduction of distance to target, no postoperative changes in nasal soft tissue, and easier instrumentation.

Bile salt supplementation acts via the farnesoid X receptor to alleviate lipopolysaccharide-induced intestinal injury.

BACKGROUND: Intestinal barrier integrity may be disrupted in many conditions allowing for bacterial invasion and ensuing systemic illness. We investigated the efficacy and mechanism of bile salts in protecting the intestinal mucosa integrity after injury through stimulation of cell proliferation and an increased resistance to apoptosis. METHODS: Over 7 days, wild-type C57Bl/6J and Nr1h4(tm1Gonz)/J (farnesoid X receptor [FXR] knockout) male mice received either liquid rodent chow alone (for control animals) or with added 50 mg/kg per day of taurodeoxycholic acid (TDCA; for experimental animals). On day 6, all mice received 10 mL/kg of lipopolysaccharide intraperitoneally. On day 7, small intestines were harvested. After immunohistochemistry with hematoxylin and eosin, activated caspase-3, and 5-bromo2'-deoxy-uridine (BrdU), mean proliferating and apoptotic cells were determined with light microscopy. In vitro, FXR proteins were immunoblotted from cultured cells after exposure to TDCA. FXR expression was then inhibited in the presence and absence of TDCA. Intestinal epithelial proliferation along with c-Myc and FXR protein expressions were determined. RESULTS: C57Bl/6J mice exhibited significant mucosal enterocyte proliferation and decreased mucosal enterocyte apoptosis when provided with supplemental TDCA in their diet. Inhibition of FXR, both in vivo and in vitro, prevented the bile salt-induced enterocyte proliferation and resistance to apoptosis. TDCA exposure stimulated nuclear translocation of FXR resulting in increased expression of c-Myc. CONCLUSION: A diet supplemented with bile salts, especially in patients who have decreased luminal bile salt, may prove beneficial and therapeutic in critical illness where intestinal injury is part of the spectrum.

Z-mammaplasty: a novel concept in mastopexy.

BACKGROUND: The inverted-T technique is the most popular skin pattern used for mastopexy, but short scar variations have increased in popularity over recent years. With respect to nipple elevation, superior, superomedial, medial, inferior, lateral, and central pedicle designs have been described. OBJECTIVES: We introduce a novel concept for mastopexy, the glandular Z-mammaplasty, and assess its anatomic and technical feasibility. METHODS: Glandular Z-plasty was performed on 15 human female cadavers. Various parameters were measured pre- and postoperatively to assess degree of ptosis and subsequently compared by student t test. RESULTS: Average pre and postoperative breast width (28.5 ± 4.7 cm, 26.7 ± 3.2 cm, P = .009), breast length (25 ± 6.6 cm and 21.8 ± 4.3 cm P = .005), breast height (10.7 ± 3.7 cm and 9.5 ± 2.9 cm, P = .02), and ptosis degree (1.9 ± 0.9 cm and 0.3 ± 0.5 cm, P < .0001) were determined. Inferior limb transposition moved the nipple closer to the sternal notch and sternum midline an average of 5.3 ± 2.2 cm and 2.4 ± 1.7 cm, respectively. The average Z-plasty degree was 34.5 ± 8.2°. The average central limb length was 8.7 ± 2.1, and the average pedicle width was 5.4 ± 0.8 cm. Buttress support of the nipple was accomplished by caudal transposition of the superior Z-plasty flap and its inset below the nipple. CONCLUSION: We demonstrate that glandular Z-mammaplasty is indeed feasible. The grade of ptosis was statistically significantly improved, with the nipple moving superiorly an average of 5.3 cm in our study group.

The sentinel fat pads: the relationship of the ROOF and SOOF to the temporal nerve in facial rejuvenation.

BACKGROUND: A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). OBJECTIVES: The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. METHODS: Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the author's anatomical findings with data in the previous literature. RESULTS: During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. CONCLUSIONS: The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

BACKGROUND: This study sought to identify and provide preventative recommendations for potentially devastating safety violations in the operating room. METHODS: A Medline database search from 1950 to current using the terms patient safety and operating room was conducted. All topics identified were reviewed. Three patient safety violations with potential for immediate and devastating outcomes were selected for discussion using evidence-based literature. RESULTS: The search identified 2851 articles, 807 of which were directly related to patient safety in the operating room. Topics addressed by these 807 included infectious complications (26%), fires (11%), communication/teamwork (6%), retained foreign objects (3%), safety checklists (1%), and wrong-site surgery (1%). Fires, gossypiboma, and wrong-site surgery were selected for discussion. CONCLUSIONS: Although fire, gossypiboma, and wrong-site surgery should be "never events" in the operating room, they continue to persist as 3 common patient safety violations. This study provides the epidemiology, common etiologies, and evidence-based preventative recommendations for each.