Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications

OBJECTIVE

To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes.

METHODS

This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification.

RESULTS

A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery.

CONCLUSION

For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.

Predictors of 30-day complications, readmission, and postoperative length of stay in children undergoing autologous rib grafting for microtia

BACKGROUND

Predictors of outcomes in pediatric microtia surgery are not well understood within the current literature. A multi-institutional database study may reveal insights into these predictors.

OBJECTIVES

To explore the predictors of 30-day complications, 30-day readmission, and postoperative length of stay (PLOS) in pediatric microtia patients undergoing autologous rib grafting.

METHODS

The Pediatric National Surgical Quality Improvement Program was queried for details on patients with microtia (ICD-9/10 744.23/Q17.2) who underwent autologous rib grafting (CPT 21230) between 2012-2021. Demographics, comorbidities, inpatient status, 30-day complications, PLOS, and 30-day readmissions were analyzed. Statistical analyses were performed to compare the preoperative characteristics with postoperative outcomes.

RESULTS

Overall, 667 patients met the inclusion criteria. Sixty-three (9.4%) had at least one complication, and 19 (2.9%) were readmitted. Univariate analysis showed that inpatient status (p = 0.011) and race (p = 0.023) were associated with higher complication rates. Multivariate analysis revealed that outpatient status was associated with significantly lower odds of complications (OR: 0.49, 95% CI [0.27, 0.87], p = 0.018), and developmental delay was associated with higher odds of 30-day readmission (OR: 2.80, 95% CI [1.05, 7.17], p = 0.036). Longer operative time was associated with older age (13.9% increase per five-year age increase, p < 0.001) and inpatient status (35.3% increase, p < 0.001). PLOS was shorter for outpatients (45.45% shorter, p < 0.001) and cases performed by plastic surgeons (14.2% shorter, p < 0.001).

CONCLUSION

Microtia reconstruction using autologous cartilage is a relatively safe procedure with low complication and readmission rates. Significant predictors of postoperative outcomes include inpatient status, race, developmental delay, and age. These findings highlight the importance of considering these factors in surgical planning and patient counseling.

Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy

Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04444-3.

Automatic surgical phase recognition-based skill assessment in laparoscopic distal gastrectomy using multicenter videos

BACKGROUND

Gastric surgery involves numerous surgical phases; however, its steps can be clearly defined. Deep learning-based surgical phase recognition can promote stylization of gastric surgery with applications in automatic surgical skill assessment. This study aimed to develop a deep learning-based surgical phase-recognition model using multicenter videos of laparoscopic distal gastrectomy, and examine the feasibility of automatic surgical skill assessment using the developed model.

METHODS

Surgical videos from 20 hospitals were used. Laparoscopic distal gastrectomy was defined and annotated into nine phases and a deep learning-based image classification model was developed for phase recognition. We examined whether the developed model's output, including the number of frames in each phase and the adequacy of the surgical field development during the phase of supra-pancreatic lymphadenectomy, correlated with the manually assigned skill assessment score.

RESULTS

The overall accuracy of phase recognition was 88.8%. Regarding surgical skill assessment based on the number of frames during the phases of lymphadenectomy of the left greater curvature and reconstruction, the number of frames in the high-score group were significantly less than those in the low-score group (829 vs. 1,152, P < 0.01; 1,208 vs. 1,586, P = 0.01, respectively). The output score of the adequacy of the surgical field development, which is the developed model's output, was significantly higher in the high-score group than that in the low-score group (0.975 vs. 0.970, P = 0.04).

CONCLUSION

The developed model had high accuracy in phase-recognition tasks and has the potential for application in automatic surgical skill assessment systems.

Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction

Importance

Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time.

Objective

To examine the association of head and neck cancer resection and reconstruction interventions with operative time.

Design, Setting, and Participants

This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022.

Interventions

The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning.

Main Outcomes and Measures

The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time.

Results

A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time.

Conclusions

The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

Quantifying the Opportunity Cost of Neurosurgical Resident Education

BACKGROUND/OBJECTIVE

Education is at the core of neurosurgical residency, but little research in to the cost of neurosurgical education exists. This study aimed to quantify costs of resident education in an academic neurosurgery program using traditional teaching methods and the Surgical Autonomy Program (SAP), a structured training program.

METHODS

SAP assesses autonomy by categorizing cases into zones of proximal development (opening, exposure, key section, and closing). All first-time, 1-level to 4-level anterior cervical discectomy and fusion (ACDF) cases between March 2014 and March 2022 from 1 attending surgeon were divided into 3 groups: independent cases, cases with traditional resident teaching, and cases with SAP teaching. Surgical times for all cases were collected and compared within levels of surgery between groups.

RESULTS

The study found 2140 ACDF cases, with 1758 independent, 223 with traditional teaching, and 159 with SAP. For 1-level to 4-level ACDFs, teaching took longer than it did with independent cases, with SAP teaching adding additional time. A 1-level ACDF performed with a resident (100.1 ± 24.3 minutes) took about as long as a 3-level ACDF performed independently (97.1 ± 8.9 minutes). The average time for 2-level cases was 72.0 ± 18.2 minutes independently, 121.7 ± 33.7 minutes traditional, and 143.4 ± 34.9 minutes SAP, with significant differences among all groups.

CONCLUSIONS

Teaching takes significant time compared with operating independently. There is also a financial cost to educating residents, because operating room time is expensive. Because attending neurosurgeons lose time to perform more surgeries when teaching residents, there is a need to acknowledge surgeons who devote time to training the next generation of neurosurgeons.

Assessment of Team Dynamics and Operative Efficiency in Hip and Knee Arthroplasty

Importance

Surgical team communication is a critical component of operative efficiency. The factors underlying optimal communication, including team turnover, role composition, and mutual familiarity, remain underinvestigated in the operating room.

Objective

To assess staff turnover, trainee involvement, and surgeon staff preferences in terms of intraoperative efficiency.

Design, Setting, and Participants

Retrospective analysis of staff characteristics and operating times for all total joint arthroplasties was performed at a tertiary academic medical center by 5 surgeons from January 1 to December 31, 2018. Data were analyzed from May 1, 2021, to February 18, 2022. The study included cases with primary total hip arthroplasties (THAs) and primary total knee arthroplasties (TKAs) comprising all primary total joint arthroplasties performed over the 1-year study interval.

Exposures

Intraoperative turnover among nonsurgical staff, presence of trainees, and presence of surgeon-preferred staff.

Main Outcomes and Measures

Incision time, procedure time, and room time for each surgery. Multivariable regression analyses between operative duration, presence of surgeon-preferred staff, and turnover among nonsurgical personnel were conducted.

Results

A total of 641 cases, including 279 THAs (51% female; median age, 64 [IQR, 56.3-71.5] years) and 362 TKAs (66% [238] female; median age, 68 [IQR, 61.1-74.1] years) were considered. Turnover among circulating nurses was associated with a significant increase in operative duration in both THAs and TKAs, with estimated differences of 19.6 minutes (SE, 3.5; P < .001) of room time in THAs and 14.0 minutes (SE, 3.1; P < .001) of room time in TKAs. The presence of a preferred anesthesiologist or surgical technician was associated with significant decreases of 26.5 minutes (SE, 8.8; P = .003) of procedure time and 12.6 minutes (SE, 4.0; P = .002) of room time, respectively, in TKAs. The presence of a surgeon-preferred vendor was associated with a significant increase in operative duration in both THAs (26.3 minutes; SE, 7.3; P < .001) and TKAs (29.6 minutes; SE, 9.6; P = .002).

Conclusions and Relevance

This study found that turnover among operative staff is associated with procedural inefficiency. In contrast, the presence of surgeon-preferred staff may facilitate intraoperative efficiency. Administrative or technologic support of perioperative communication and team continuity may help improve operative efficiency.

Multivariable Cost Frontiers-Qualitative Financial Analyses Using Operational Metrics From the Implementation of a Surgery Fellowship

OBJECTIVE

We expand the application of cost frontiers and introduce a novel approach using qualitative multivariable financial analyses.

SUMMARY BACKGROUND DATA

With the creation of a 5 + 2-year fellowship program in July 2016, the Division of Vascular Surgery at the University of Vermont Medical Center altered the underlying operational structure of its inpatient services.

METHOD

Using WiseOR (Palo Alto, CA), a web-based OR management data system, we extracted the operating room metrics before and after August 1, 2016 service for each 4-week period spanning from September 2015 to July 2017. The cost per minute modeled after Childers et al's inpatient OR cost guidelines was multiplied by the after-hours utilization to determine variable cost. Zones with corresponding cutoffs were used to graphically represent cost efficiency trends.

RESULTS

Caseload/FTE for attending surgeons increased from 11.54 cases per month to 13.02 cases per month ( P = 0.0771). Monthly variable costs/FTE increased from $540.2 to $1873 ( P = 0.0138). Monthly revenue/FTE increased from $61,505 to $70,277 ( P = 0.2639). Adjusted monthly reve-nue/FTE increased from $60,965 to $68,403 ( P = 0.3374). Average monthly percent of adjusted revenue/FTE lost to variable costs increased from 0.85% to 2.77% ( P = 0.0078). Adjusted monthly revenue/case/FTE remained the same from $5309 to $5319 ( P = 0.9889).

CONCLUSION

In summary, we demonstrate that multivariable cost (or performance) frontiers can track a net increase in profitability associated with fellowship implementation despite diminishing returns at higher caseloads.

Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?

BACKGROUND

The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes.

METHODS

We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons' experience.

RESULTS

The median total surgical time for a trainee's first LC was 112 (range 71-226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46-252 min) and the next 50-59 cases (64, 34-198 min), but not between the 50-59 and the subsequent 100-109 cases (71, 33-127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient's acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50-59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases.

CONCLUSION

The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.

Impact of Prolonged Operative Time on Complications Following Endoscopic Sinonasal Surgery

OBJECTIVE

To determine how prolonged operative time (POT) impacts 30-day outcomes in patients undergoing endoscopic sinonasal surgery (ESNS).

STUDY DESIGN

Retrospective study.

METHODS

Data from patients who underwent ESNS (nonsinus, sinus, and extended sinus) between 2005 to 2018 were collected from the American College of Surgeons National Surgical Quality Improvement database. Univariate and multivariate analyses were performed to evaluate the effect of POT on postoperative outcomes.

RESULTS

Among 1,994 ESNS cases, 495 nonsinus procedures, 1,191 sinus procedures, and 308 extended sinus procedures were identified. Median OT was 90 minutes (interquartile range [IQR], 51-165 minutes) for nonsinus procedures, 113 minutes (IQR, 66-189 minutes) for sinus procedures, and 187 minutes (IQR, 137-251 minutes) for extended sinus procedures. Other than older age (P = .008), POT was not significantly associated with baseline demographics and comorbidities for patients undergoing non-sinus procedures. Older age (P < .001), White and Black race (P < .001), ASA physical classifications III or IV (P < .001), and several preoperative comorbidities, including obesity (P = .045), and hypertension (P < .001) were associated with POT for sinus procedures. Older age (P = .030), male sex (P = .010), and lower body mass index (P = .004) were associated with POT for extended sinus procedures. After risk-adjustment, POT was independently associated with prolonged hospital stay (LOS) for all procedure categories, and associated with overall surgical complications and postoperative bleeding for sinus and extended sinus procedures specifically.

CONCLUSION

POT is independently associated with several adverse outcomes following ESNS, including prolonged LOS, overall surgical complications, and bleeding. Preoperative planning should include optimizing modifiable patient risk factors for POT and identifying surgeon-specific factors to enhance surgical efficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:51-58, 2023.

Septoplasty Training During the COVID-19 Era: Development and Validation of a Novel Low-Cost Simulation Model

OBJECTIVE

In a context of increasingly limited surgical exposition, enhanced by the coronavirus disease 2019 (COVID-19) pandemic context, the objective of this article is to explain the development of a novel low-cost and simple replication animal-based septoplasty training model for otolaryngology residents, to assess its face and construct validity, and to validate a specific rating scale for each task.

STUDY DESIGN

Experimental study.

SETTING

Surgical simulation laboratory.

METHODS

Septoplasty experts divided the procedure into key tasks. A simulator model to perform tasks was developed using pig ears to imitate human nasal septum cartilage, and a Specific Rating Scale was constructed. Trainees and faculty performed all tasks in the model. The participants were videotaped, and operative time, hand movements, and path length were recorded using a motion sensor device. Two blinded experts evaluated the videos with Global and Specific Rating Scales. All participants answered a satisfaction survey.

RESULTS

Fifteen subjects were recruited (7 trainees and 8 faculty). Significantly higher Global Rating Scale score, shorter operative time and path length, and fewer hand movements were observed in the faculty group. The satisfaction survey showed high applicability to a real scenario (mean score of 4.6 out of 5). Specific Rating Scale showed construct and concurrent validity and high reliability.

CONCLUSION

This simulation model and its specific rating scale can be accurately used as a validated surgical assessment tool for endonasal septoplasty skills. Its low cost and simple replicability make it a potentially useful tool in any otolaryngology surgical training program.

Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial

Background: Distance learning is an interactive way of education when teachers and students are physically separated. Our purpose was to examine its effectivity in training of basic surgical techniques and to provide an alternative sustainable methodology for the training of medical professionals. Methods: Sixty students were involved in our single blinded randomized controlled study. Six homogenized groups were created then randomized into three groups of distance learning and three groups of in-person teaching. The groups completed the same curriculum using our own “SkillBox”. All students took the same pre- and post-course test evaluated blindly. The students filled out an online feedback form after the course. A financial analysis was also made. Results: There was no significant difference in the post-course exam results (distance 28.200 vs. in-person 25.200). We managed to achieve significantly better improvements in the distance learning of suturing (distance 19.967 vs. in-person 15.900, p = 0.043). According to 93% of the study group students, the quality of teaching did not decrease compared to the traditional classes. Conclusion: The results of the students improved similarly in distance learning and in-person education. The online form of teaching was received positively among the students; they found it an effective and good alternative.

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

OBJECTIVE

To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary academic hospital.

METHODS

This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded.

RESULTS

A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding.

CONCLUSION

Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

[Time management in operating rooms-a cross-sectional study to evaluate estimated and objective durations of otorhinolaryngologic surgical procedures]

Hintergrund

Die Gestaltung des Operations(Op.)-Programms im klinischen Alltag ist von hoher Wichtigkeit für die Wirtschaftlichkeit. Gleichzeitig muss die Einhaltung von Arbeitszeiten unterschiedlicher Berufsgruppen berücksichtigt werden.

Ziel der Arbeit

Um Fehlerquellen bei der Planung aufzudecken, wurden durch Chirurgen geschätzte mit objektiv erhobenen Zeiten (u. a. Schnitt-Naht-Zeit) verglichen.

Material und Methoden

In einer retrospektiven Analyse wurden 1809 Operationen im Jahr 2018 (22 verschiedene Op.-Arten) durch 31 Operateure (12 Fach- [FÄ] und 19 Assistenzärzte [AÄ]) hinsichtlich ihrer Dauer verglichen und mittels Mann-Whitney-U-Test auf Signifikanz geprüft.

Ergebnisse

Der Vergleich der objektiven Zeiten von FÄ und AÄ zeigt signifikante Unterschiede in der Schnitt-Naht-Zeit bzw. der Summe aus Schnitt-Naht-Zeit und Zeit der chirurgischen Maßnahmen für 6 von 15 Op.-Arten (p < 0,001). Die durch FÄ geschätzte Nachbereitungszeit wich bei 2 von 22 Op.-Arten von der objektiven Zeit ab (p < 0,05), die durch AÄ geschätzte Zeit bei 7 von 15 Op.-Arten (p < 0,05). Hinsichtlich der Schnitt-Naht-Zeit verschätzten sich FÄ bei 7 von 22 (p < 0,05), AÄ bei 3 von 15 (p < 0,05) Op.-Arten. Die durch FÄ geschätzte Vorbereitungszeit wich bei 16 von 22 Op.-Arten signifikant von der objektiven Zeit ab (p < 0,05), bei AÄ bei 7 von 15 (p < 0,001). Vor- und Nachbereitungszeiten wurden durch FÄ unter‑, Schnitt-Naht-Zeiten überschätzt. AÄ unterschätzten alle Zeiten.

Schlussfolgerung

Bei der OP-Planung muss die Erfahrung des durchführenden Chirurgen berücksichtigt werden. Eine Verbesserung durch verminderte subjektive Fehleinschätzung kann möglicherweise mithilfe spezieller Algorithmen gelingen.

Flipping the Classroom: An Evaluation of Teaching and Learning Strategies in the Operating Room

OBJECTIVES

With increasing restraints on resident's experiences in the operating room, with causes ranging from decreased time available to increasing operating room costs, focus has been placed on how to improve resident's education. The objectives of our study are to (1) determine barriers in education in the operating room, (2) identify effective learning and teaching strategies for residents in the operating room with a focus on the tonsillectomy procedure.

METHODS

An online survey was sent to all otolaryngology residents and residency programs for which contact information was available from January 2016 to March 2016 with 139 respondents. The 12-question survey focused on information regarding limitations to learning how to perform tonsillectomies as well as difficulties with teaching the same procedure. Resident responses were separated based on PGY level, and analysis was performed using t-tests and Chi squared analysis.

RESULTS

Common themes emerged from responses for both teaching and learning how to perform tonsillectomies. A significant limitation in learning the procedure was lack of visualization during the surgery (57% learning vs 60% teaching). For both learners and teachers, the monopolar cautery instrument was found to be the most preferred instrument to use during tonsillectomy (80% each). The majority of resident respondents (93%) felt that an instructional video would be beneficial for both learning and teaching the procedure.

CONCLUSIONS

Significant limitations for learning and teaching in the operating room were identified for performing tonsillectomies. Future endeavors will focus on resolving these limitations to improve surgical education.

EVIDENCE LEVEL

Level IV.

[Multimodal training concept for temporal bone surgery]

BACKGROUND

Surgical training is increasingly supported by the use of simulators. For temporal bone surgery, shown here by means of mastoidectomy, there are other training models besides cadaver specimens, such as artificial temporal bones or computer-based simulators.

OBJECTIVES

A structured training concept was created which integrates different training methods of mastoidectomy with regard to effectiveness and current learning theory in education.

METHOD

A selective literature research was conducted to compare learning-theoretical findings and the availability and effectiveness of currently existing training models.

RESULTS

To acquire surgical skills, a stepwise approach is suggested. Depending on the progress with computer-based simulation, plastic or native temporal bones should be used. To achieve a plateau of the learning curve, approximately 25 semi-autonomous preparations are recommended. Different 'Objective Structured Assessments of Technical Skills' (OSATS) are implemented to assess the learning progress at different levels.

DISCUSSION

Simulation-based training is recommended until an adequate learning curve plateau is achieved. This is reasonable for patient safety, based on limited accessibility of human cadaveric temporal bones but also by findings of the learning theory.

CONCLUSION

The curriculum integrates different training models of mastoidectomy and OSATS into an overall concept. The training plan has to be continuously adapted to new findings and technical developments.

Preoperative Criteria Predict Operative Time Variability Within Tympanoplasty Procedures

OBJECTIVE

To identify preoperative patient and surgical parameters that predict operative time variability within tympanoplasty current procedural terminology (CPT) codes.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

One hundred twenty eight patients who underwent tympanoplasty (CPT code 69631) or tympanoplasty with ossicular chain reconstruction (69633) by a single surgeon over 3 years.

INTERVENTIONS

Procedures were preoperatively assigned a complexity modifier: Level 1 (small or posterior perforation able to be repaired via transcanal approach), Level 2 (large perforation or other factor requiring postauricular approach), or Level 3 (cholesteatoma or severe infection).

MAIN OUTCOME MEASURES

Total in-room time (nonoperative time plus actual operative time).

RESULTS

Consideration of preoperative parameters including surgical complexity, surgical facility, use of facial nerve monitoring, laser usage, resident involvement, revision surgery, and underlying patient characteristics (American Society of Anesthesiologists [ASA] score, body mass index [BMI]) accounted for up to 69% of surgical time variance. Across both CPT codes, surgical complexity levels accurately stratified operative times (p < 0.05). Total time was longer (by 30.0 min for 69631, 55.4 min for 69633) in Level 3 procedures compared with Level 2, while Level 1 cases were shorter (27.6, 33.9 min). Resident involvement added 25 and 32 minutes to total time (p < 0.02). Nonoperative preparation times were longer (22.1, 15.4 min) in the main hospital compared with ambulatory surgical center (p < 0.001).

CONCLUSIONS

There is significant surgical time variability within tympanoplasty CPT codes, which can be accurately predicted by the preoperative assignment of complexity level modifiers and consideration of patient and surgical factors. Application of complexity modifiers can enable more efficient surgical scheduling.

Evaluation and implementation of a mannequin-based surgical simulator for margin-involving eyelid laceration repair - a pilot study

BACKGROUND

Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment.

METHODS

We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences.

RESULTS

Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience.

CONCLUSIONS

We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees' surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective.

Influence of team composition on turnover and efficiency of total hip and knee arthroplasty

AIMS

Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty.

METHODS

We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score.

RESULTS

Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon's 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043).

CONCLUSION

Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347-352.

A Pilot Study of Surgical Trainee Participation in Humanitarian Surgeries

BACKGROUND

The impact of general surgery resident participation on operative case time and postoperative complications has been broadly studied in the United States. Although surgical trainee involvement in international humanitarian surgical care is escalating, there is limited information as to how this participation affects care rendered. This study examines the impact of trainee involvement on case length and immediate postoperative complications with regard to operations in low- and middle-income settings.

METHODS

A retrospective chart review was conducted of humanitarian surgeries completed during annual short-term surgical missions performed by the International Surgical Health Initiative to Ghana and Peru. Between 2017 and 2019, procedures included inguinal hernia repairs and total abdominal hysterectomies (TAHs). Operative records were reviewed for case type, duration, and immediate postoperative complications. Cases were categorized as involving two attending co-surgeons (AA) or one attending and resident assistant (RA).

RESULTS

There were 135 operative cases between 2017 and 2019; the majority (82%) involved a resident assistant. There were no statistically significant differences in case times between the attending assistant (AA) and resident assistant (RA) cohorts in both case types. All 23 postoperative complications were classified as Clavien-Dindo Grade I. In addition, resident assistance did not lead to a statistically significant increase in complication rate; 26% in the AA cohort versus 74% in the RA cohort (P = 0.3).

CONCLUSIONS

This pilot study examining 135 operative cases over 2 y of humanitarian surgeries demonstrates that there were no differences in operative duration or complication rates between the AA and RA cohorts. We propose that surgical trainee involvement in low- and middle-income settings do not adversely impact operative case times or postoperative complications.

Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach

BACKGROUND

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure.

METHODS

Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT.

RESULTS

A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R² of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001).

CONCLUSIONS

We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.

Single-surgeon parotidectomy outcomes in an academic center experience during a 15-year period

OBJECTIVE

As large single-surgeon series in the literature are lacking, we sought to review a single-surgeon's experience with parotidectomy in an academic center, with a focused analysis of pathology, technique, and facial nerve (FN) weakness. Benchmark values for complications and operative times with routine trainee involvement and without continuous FN monitoring are offered.

MATERIALS AND METHODS

All patients who underwent parotidectomy, performed by D. G. D., for benign and malignant disease between January 2004 and December 2018 at an academic center were reviewed.

RESULTS

A total of 924 parotidectomies, with adequate evaluatable data were identified. The majority of patients had benign tumors (70.9%). Partial/superficial parotidectomy was the most common approach (65.7%). Selective FN branch sacrifice was rare (12.3%), but significantly more common among patients with malignant pathology (33.8% vs 3.5% for benign, P < .0001). Among patients with intact FN, post-operative short- and long-term FN weaknesses were rare (6.5% and 1.7%, respectively). These rates were lower among patients with benign tumors (5.4% and 1.3%). Partial/superficial parotidectomy for benign tumors was associated with a low rate of short- and long-term FN weaknesses (2.7% and 0.9%). Mean OR time was 185 minutes.

CONCLUSION

This is the largest single-surgeon series on parotidectomy, spanning 15 years. We demonstrate excellent long- and short-term FN paresis rates with acceptable operative times without regular use of continuous FN monitoring and with routine trainee involvement. These findings may provide valuable insight into parotid tumor pathology, FN outcomes, and feasibility and expectations of performing parotidectomy in an academic setting.

LEVEL OF EVIDENCE

4.

Analysis of 1478 Cases of Hypospadias Repair: The Incidence of Requiring Repeated Anesthetic Exposure as Well as Exploration of the Involvement of Trainees on Case Duration

BACKGROUND

Recently, there has been significant focus on the effects of anesthesia on the developing brain. Concern is heightened in children <3 years of age requiring lengthy and/or multiple anesthetics. Hypospadias correction is common in otherwise healthy children and may require both lengthy and repeated anesthetics. At academic centers, many of these cases are performed with the assistance of anesthesia and surgical trainees. We sought to identify both the incidence of these children undergoing additional anesthetics before age 3 as well as to understand the effect of trainees on duration of surgery and anesthesia and thus anesthetic exposure (AE), specifically focusing on those cases >3 hours.

METHODS

We analyzed all cases of hypospadias repair from December 2011 through December 2018 at Texas Children's Hospital. In all, 1326 patients undergoing isolated hypospadias repair were analyzed for anesthesia time, surgical time, provider types involved, AE, caudal block, and additional AE related/unrelated to hypospadias.

RESULTS

For the primary aim, a total of 1573 anesthetics were performed in children <3 years of age, including 1241 hypospadias repairs of which 1104 (89%) were completed with <3 hours of AE. For patients with <3 hours of AE, 86.1% had a single surgical intervention for hypospadias. Of patients <3 years of age, 17.3% required additional nonrelated surgeries. There was no difference in anesthesia time in cases performed solely by anesthesia attendings versus those performed with trainees/assistance (16.8 vs 16.8 minutes; P = .98). With regard to surgery, cases performed with surgical trainees were of longer duration than those performed solely by surgical attendings (83.5 vs 98.3 minutes; P < .001). Performance of surgery solely by attending surgeon resulted in a reduced total AE in minimal alveolar concentration (MAC) hours when compared to procedures done with trainees (1.92 vs 2.18; P < .001). Finally, comparison of patients undergoing initial correction of hypospadias with subsequent revisions revealed a longer time (117.7 vs 132.2 minutes; P < .001) and AE during the primary stage.

CONCLUSIONS

The majority of children with hypospadias were repaired within a single AE. In general, most children did not require repeated AE before age 3. While presence of nonattending surgeons was associated with an increase in AE, this might at least partially be due to differences in case complexity. Moreover, the increase is likely not clinically significant. While it is critical to maintain a training environment, attempts to minimize AE are crucial. This information facilitates parental consent, particularly with regard to anesthesia duration and the need for additional anesthetics in hypospadias and nonhypospadias surgeries.

Three-Dimensionally Printed Patient-Specific Surgical Plates Increase Accuracy of Oncologic Head and Neck Reconstruction Versus Conventional Surgical Plates: A Comparative Study

Background

Surgeons are pursuing accurate head and neck reconstruction to enhance aesthetic and functional outcomes after oncologic resection. This study aimed to investigate whether accuracy of head and neck reconstruction is improved with the use of three-dimensionally (3D)-printed patient-specific surgical plates compared with conventional plates.

Methods

In this comparative study, patients were prospectively recruited into the study group (3DJP16) with 3D-printed patient-specific surgical plates. The patients in control group with conventional surgical plates were from a historic cohort in the same unit. The primary end point of the study was the accuracy of head and neck reconstruction. The secondary end points were accuracy of osteotomy, intraoperative blood loss, total operative time, and length of hospital stay.

Results

The study recruited of 33 patients, including 17 in the study group and 16 in the control group. The patients’ baseline characteristics were similar between the two groups. The absolute distance deviation of the maxilla or mandible was 1.5 ± 0.5 mm in the study group and 2.1 ± 0.7 mm in the control group [mean difference, − 0.7 mm; 95% confidence interval (CI) − 1.1 to − 0.3; p = 0.003], showing superior accuracy of reconstruction for the patients with 3D-printed patient-specific surgical plates. Improved accuracy of reconstruction also was detected in terms of bilateral mandibular angles and bone grafts. Concerning the secondary end points, the accuracy of the osteotomy was similar in the two groups. No difference was found regarding intraoperative blood loss, total operative time, or length of hospital stay.

Conclusions

This is the first study to prove that compared with conventional plates, 3D-printed patient-specific surgical plates improve the accuracy of oncologic head and neck reconstruction.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08732-y) contains supplementary material, which is available to authorized users.

A model to predict postoperative complications for otorhinolaryngology and maxillofacial surgery procedures in elderly patients

PURPOSE

All kinds of ear, nose, and throat and maxillofacial surgery (ENT/MFS) procedures are being increasingly performed in the elderly although old age is a major risk factor for increased postoperative complications. With only scarce evidence on the topic, surgeons are asked to critically evaluate their procedures' indications and outcomes to balance the treatment risks and benefits. Our primary aim was to identify predictive factors for surgical outcomes in this setting and to create a predictive model for a tailored risk assessment.

METHODS

We analyzed a case series of 435 patients from an institutional clinical database at our academic tertiary care center. Multivariate logistic regression was used to identify all possible covariates and nomograms using stepwise backward method were generated. The performance was assessed by calibration curves and c-index.

RESULTS

Overall complication rate was 18.3% within the first 30 days and the need for re-intervention was 5.9%. For those under general anesthesia, we identified specific risk factors and developed three risk-predicting models of overall, early, and late complications. All of the nomograms showed satisfactory accuracy with a c-index of 0.83, 0.75, 0.86, and 0.82, respectively.

CONCLUSION

Using clinical preoperative variables, we constructed a model for predicting major adverse events in ENT/MFS patients. In our experience, patients over 65 showed a non-negligible risk for postoperative complications depending on several factors. Such tools might help in decision-making, by increasing the risk-awareness of clinicians, to better address peri-operative and post-operative care of these patients.

Safety of tympanoplasty and ossiculoplasty performed by otorhinolaryngology trainees

OBJECTIVE

This study aimed to examine the impact of trainee involvement in performing tympanoplasty or tympano-ossiculoplasty on outcomes.

METHODS

A retrospective analysis was performed of a prospective database of all patients undergoing tympanoplasty and tympano-ossiculoplasty in a single centre during a three-year period. Patients were divided into three primary surgeon groups: consultants, fellows and residents. The outcomes of operative time, surgical complications, length of hospital stay, and air-bone gap improvement were compared among the groups.

RESULTS

The study included 398 tympanoplasty and tympano-ossiculoplasty surgical procedures, 71 per cent of which were performed by junior trainees (residents). The junior trainee group was associated with a significantly longer surgical time, without adverse impact on outcomes.

CONCLUSION

Trainee participation in tympanoplasty and tympano-ossiculoplasty surgery was associated with longer surgical time, but did not negatively affect the peri-operative course or hearing outcome. Therefore, resident involvement in these types of surgery is safe.

Association of Surgical Setting and Deployment of a New Electronic Health Record With Ophthalmic Operative Times

Importance

Determining the association of surgical setting and implementation of a new electronic health record (EHR) system with ophthalmic operative times is important for surgical planning and resource allocation.

Objective

To assess the associations of surgical setting and EHR system replacement with operative times for ophthalmic surgery.

Design, Setting, and Participants

This case series included ophthalmic surgeries from July 2015 to November 2016 in 2 ambulatory surgical centers and 1 hospital outpatient department in a single academic eye institute. Operative times from consecutive surgical cases performed by board-certified ophthalmologists were extracted from 2 EHR systems. Those performed after replacement EHR system implementation were divided into three 50-day time categories (immediate posttransition, intermediate posttransition, and late posttransition periods). Multivariable regression analyses assessed the associations of surgical setting (hospital outpatient department vs ambulatory surgical center) with total operating room times for comparable surgeons performing cataract surgery and deployment of a new EHR system in the OR on several operative time measures. Data were evaluated from November 2016 to March 2018.

Main Outcomes and Measures

Room duration, procedure duration, turnaround time, and total OR time.

Results

A total of 11 064 cases performed by 76 surgeons were included in this analysis. The mean total OR time was 2.9 (95% CI, 0.5-5.4; P = .02) minutes longer in the immediate posttransition period and 1.2 (95% CI, 0.1-2.2; P = .04) minutes longer in the intermediate posttransition period relative to surgeries performed before EHR system replacement. No difference in the total OR time was found between the late posttransition and pretransition periods. Relative to ambulatory surgical centers, the mean total OR time was 15.9 (95% CI, 14.7-17.0) minutes longer, and the mean turnaround time was 5.1 (95% CI, 4.3-6.0) minutes longer at the hospital outpatient department for comparable surgeons performing cataract surgery (P < .001 for both).

Conclusions and Relevance

The mean total OR time per case lengthened after the replacement of an EHR system in the OR, but this increase was small (shorter than 3 minutes) and limited to surgeries performed during the first 100 days after the EHR system transition. Modeling to assess surgical setting demonstrated all operative time measures were longer for cataract cases performed at the hospital outpatient department relative to those at ambulatory surgical centers. These data have implications for the fiscal and logistical management of ophthalmic surgery.

Impact of medical student involvement on outcomes following spine surgery: A single center analysis of 6485 patients

Medical student (MS) observation and assistance in the operating room (OR) is a critical component of medical education. Though participation in the operating room has many benefits to the medical student, the potential cost of these experiences to the patients must be taken into account. Other studies have shown differences in outcomes with resident involvement, but the effect of medical students in the OR has been poorly understood. The objective of this study was to understand how medical students and residents impacted surgical outcomes in posterior spinal fusions, anterior cervical discectomy and fusions (ACDFs), and lumbar discectomies. We conducted a retrospective study of patients undergoing posterior spinal fusions, ACDFs, and lumbar discectomies over 15 years. There were 6485 patients met the inclusion criteria of either undergoing a posterior fusion, ACDF or lumbar discectomy (1250 posterior fusion, 1381 ACDF, 3854 lumbar discectomies). Overall, little difference was observed when a medical student was present for surgical outcomes including length of stay, infection, and readmission. For ACDFs, having a medical student present had a significantly longer procedure durations (OR = 1.612, p = 0.001) than cases without. Besides slightly longer operative time (in posterior fusions), there were no major differences in outcomes when a medical student was present in the OR.

Collagen Allografts Compared With Autologous Tissue in Tympanoplasty

OBJECTIVE

There are no direct comparisons between the success of collagen allografts versus traditional autografts for tympanic membrane (TM) repair. We sought to compare success rates in a large series of patients undergoing tympanoplasty using collagen allografts versus autologous tissues.

STUDY DESIGN

Retrospective review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Single institution retrospective chart review was performed for adult subjects with TM perforation undergoing tympanoplasty. Demographic, clinical, and surgical data were collected. Statistical analysis was completed using Rstudio. Each factor was examined to assess effect on graft success rate using logistic regression.

RESULTS

Two hundred sixty-five surgeries met criteria with four main grafting materials or combinations thereof. The overall graft success rate was 81.1% with failure rate of 18.9%. There was no significant association between failure rates and: age, sex, perforation cause, size, and location, primary or revision status, middle ear status (wet or dry), concomitant procedures (mastoidectomy or ossiculoplasty), presence of active cholesteatoma, or surgical technique. Although not statistically significant, the odds of success for perichondrium + cartilage were 7.5 times higher than collagen allografts (p = 0.07, 95% confidence interval [CI] = 0.81-69.6). The odds of success for the postauricular (odds ratio [OR] = 6.4) and transcanal approaches (OR = 24.8) were significantly greater than for endaural (p = 0.007 and p = 0.008, respectively).

CONCLUSION

In tympanoplasty surgeries performed on patients with TM perforation, we found no statistically significant difference in graft failure rates between collagen allograft and other grafting materials or combinations, though the higher odds ratio of success with cartilage + perichondrium may be clinically relevant.

Time, Resident Involvement, and Supply Drive Cost Variability in Septoplasty with Turbinate Reduction

Objective To determine factors that influence cost variability in septoplasty with inferior turbinate reduction. Study Design Case series with chart review. Setting Tertiary care hospital and affiliated ambulatory surgical center. Subjects and Methods Surgical costs were reviewed for adult patients undergoing septoplasty with inferior turbinate reduction between December 2014 and September 2017. Cases where additional procedures were performed were excluded. Operative supply costs, operative time, room time, and resident involvement were determined. Contribution of these factors to total costs and variability were analyzed. Results The study included 116 patients (mean age, 38 years) and 4 faculty surgeons. Total cost was primarily driven by operative time (74%), with a smaller portion of total cost arising from supplies (26%). Time cost ( P < .0001) and supply cost ( P = .006) varied significantly among surgeons. A resident was involved in 46.6% of cases. When subanalyzed by resident year, no-resident and senior resident (postgraduate years 4 and 5) cases had nearly identical mean times, while junior resident (postgraduate years 1-3) cases had mean times and operative time costs that were 39% greater ( P < .001). Conclusion For septoplasty with inferior turbinate reduction, the greatest driver of cost variation was operative time. Resident involvement correlated with increased time and cost. Supply costs had a much smaller impact. When subanalyzed by resident year, junior resident-involved cases were significantly longer than no-resident cases.

The Impact of Resident Involvement in Elective Posterior Cervical Fusion

STUDY DESIGN

Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery.

SUMMARY OF BACKGROUND DATA

Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest.

RESULTS

A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023).

CONCLUSION

The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity.

LEVEL OF EVIDENCE

3.

Effects of Surgical Assistant's Level of Resident Training on Surgical Treatment of Intermittent Exotropia: Operation Time and Surgical Outcomes

Purpose

To evaluate the effects of the surgical assistant's level of resident training on operation time and surgical outcome in the surgical treatment of intermittent exotropia.

Methods

This study included 456 patients with intermittent exotropia who underwent lateral rectus recession and medial rectus resection and were followed up for 24 months after surgery. The patients were divided into two groups according to the surgical assistant's level of resident training: group F (surgery assisted by a first-year resident [n = 198]) and group S (surgery assisted by a second-, third-, or fourth-year resident [n = 258]). The operation time and surgical outcomes (postoperative exodeviation and the number of patients who underwent a second operation) were compared between the two groups.

Results

The average operation times in groups F and S were 36.54 ± 7.4 and 37.34 ± 9.94 minutes, respectively (p = 0.33). Immediate postoperative exodeviation was higher in group F (0.79 ± 3.82 prism diopters) than in group S (0.38 ± 3.75 prism diopters). However, repeated-measures analysis of variance revealed no significant difference in exodeviation between the two groups during the 24-month follow-up period (p = 0.45). A second operation was performed in 29.3% (58 / 198) of the patients in group F, and in 32.2% (83 / 258) of those in group S (p = 0.51).

Conclusions

No significant difference in operation time was observed when we compared the effects of the level of resident training in the surgical treatment of intermittent exotropia. Although the immediate postoperative exodeviation was higher in patients who had undergone surgery assisted by a first-year resident, the surgical outcome during the 24-month follow-up was not significantly different.

Impact of Trainee Involvement in Cervical Excision Procedures: Does Trainee Involvement Impact Quality?

OBJECTIVE

Cervical excision procedures are essential to the care of cervical dysplasia and malignancy. We sought to determine whether learner involvement in cervical excision procedures affects the quality of excision specimen.

MATERIALS AND METHODS

A retrospective cohort study of cervical cancer patients diagnosed from July 1, 2000, to July 1, 2015, was performed. We included patients who had (1) a cervical excision procedure, either loop electrosurgical excision procedure or cold knife cone, and (2) pathologic information available. Primary outcome was the margin status of the specimen; secondary outcome was the size of the excision specimen including both width and depth. The exposure of interest was trainee participation, defined as resident physicians under the supervision of either a gynecologist or gynecologic oncologist. Descriptive statistics and general linear models were used for analysis.

RESULTS

Ninety-four patients were identified. Overall, 58% (n = 54) of procedures were performed with trainee involvement. There was no difference in age, body mass index, or specimen width between trainee-performed and nontrainee-performed excisions. There was no significant difference in the status of margins with or without a trainee [44/57 (77%) and 29/37 (78%), respectively, p = .89]. There was a statistically significant difference in median specimen depth between trainee-performed and nontrainee-performed cases (15.4 mm vs 12 mm, p < .02). When adjusting for age, body mass index, excision type, indication, presence of trainee, and type of supervising physician, only the indication and type of excision were associated with greater depth of excision, (p < .01).

CONCLUSIONS

Trainee involvement in cervical excision procedures does not alter the quality of excision specimen.

Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery

Objectives

To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher’s exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time.

Results

Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases.

Conclusion

Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

Assessment of Approaches of Otorhinolaryngologists in Facial Plastic and Nasal Surgery: A Survey Study

OBJECTIVE

To assess approaches and experiences of otorhinolaryngologists in facial plastic and nasal surgery.

METHODS

In total, 234 surgeons (191 males and 43 females; average age, 37.22±8.4 years; age range, 26-63 years) were included. All participants were given a questionnaire comprising 22 multiple choice and closed-ended questions. All responses to the questionnaires were analyzed.

RESULTS

Of 234 participants, 42 (17.9%) were residents and 192 (82.1%) were specialists in otorhinolaryngology. The most challenging cases in rhinoplasty were crooked nose (33.8%), ideal nasal dorsum (18.8%), revision cases (13.2%), and skin deformities (11.1%). The photodocumentation rate by surgeons before and after procedures of facial plastic surgery was 86.3%, whereas the intraoperative photodocumentation rate by surgeons was 47%. The most common facial plastic surgery procedures other than rhinoplasty were otoplasty (68.4%), filler-Botox-fat injections (20.5%), and mentoplasty (18.4%).

CONCLUSION

This survey study is quite important because it assesses approaches of otorhinolaryngologists in facial plastic surgery. Although this study provides more valuable data for determining the current status, further studies with larger number of surgeons are required.

Development and validation of a 3D-printed model of the ostiomeatal complex and frontal sinus for endoscopic sinus surgery training

BACKGROUND

Endoscopic sinus surgery poses unique training challenges due to complex and variable anatomy, and the risk of major complications. We sought to create and provide validity evidence for a novel 3D-printed simulator of the nose and paranasal sinuses.

METHODS

Sinonasal computed tomography (CT) images of a patient were imported into 3D visualization software. Segmentation of bony and soft tissue structures was then performed. The model was printed using simulated bone and soft tissue materials. Rhinologists and otolaryngology residents completed 6 prespecified tasks including maxillary antrostomy and frontal recess dissection on the simulator. Participants evaluated the model using survey ratings based on a 5-point Likert scale. The average time to complete each task was calculated. Descriptive analysis was used to evaluate ratings, and thematic analysis was done for qualitative questions.

RESULTS

A total of 20 participants (10 rhinologists and 10 otolaryngology residents) tested the model and answered the survey. Overall the participants felt that the simulator would be useful as a training/educational tool (4.6/5), and that it should be integrated as part of the rhinology training curriculum (4.5/5). The following responses were obtained: visual appearance 4.25/5; realism of materials 3.8/5; and surgical experience 3.9/5. The average time to complete each task was lower for the rhinologist group than for the residents.

CONCLUSION

We describe the development and validation of a novel 3D-printed model for the training of endoscopic sinus surgery skills. Although participants found the simulator to be a useful training and educational tool, further model development could improve the outcome.

Teaching mid-urethral sling surgery to residents: Impact on operative time and postoperative outcomes

AIMS

The purpose of this study was to determine the impact of resident teaching on outcomes of mid-urethral sling surgery.

METHODS

A retrospective review of female patients who underwent an outpatient transobturator (TOT) synthetic mid-urethral sling procedure with and without concomitant prolapse repair by two surgeons (JA, KE) in a tertiary female pelvic medicine practice was performed. Total procedure time (TPT = time from incision to closure including sling placement and any prolapse procedure), estimated blood loss (EBL), and postoperative complications including urinary retention, mesh exposure, reoperation, vaginal bleeding, and leg pain were compared between cases with and without the presence of a resident.

RESULTS

One hundred thirty-four women underwent an outpatient transobturator sling procedure. Fifty-seven patients (43%) had a concomitant prolapse procedure. A resident was present at 57% (76/134) of cases. The average observed TPT (±SEM) was 60.6 ± 3.1 min when a resident was present and 46.6 ± 2.5 min when a resident was not present (P = 0.001). However, residents were more likely to be present when concomitant procedures were performed (P = 0.003). After adjusting for this, the presence of a resident increased TPT by an estimated 7.9 ± 2.5 min (P = 0.002). There was no statistical difference in EBL or postoperative complications.

CONCLUSIONS

Resident participation in transobturator sling procedures resulted in a statistically significant, although clinically small, increase in operative time and had no significant impact on EBL or postoperative complications.

Obesity Increases Operative Time in Children Undergoing Laparoscopic Cholecystectomy

INTRODUCTION

Few studies have assessed the impact of obesity on laparoscopic cholecystectomy (LC) in pediatric patients.

MATERIALS AND METHODS

Children who underwent LC were identified from the 2012 to 2013 American College of Surgeons' National Surgical Quality Improvement Program Pediatrics data. Patient characteristics, operative details, and outcomes were compared. Multivariable logistic regression was utilized to identify predictors of increased operative time (OT) and duration of anesthesia (DOAn).

RESULTS

In total, 1757 patients were identified. Due to low rates of obesity in children <9 years old, analyses were limited to those 9-17 (n = 1611, 43% obese). Among obese children, 80.6% were girls. A higher proportion of obese patients had diabetes (3.0% versus 1.0%, P < .01) and contaminated or dirty/infected wounds (15.1% versus 9.4%, P < .01). Complication rates were low. The most frequent indications for surgery were cholelithiasis/biliary colic (34.3%), chronic cholecystitis (26.9%), and biliary dyskinesia (18.2%). On multivariable analysis, obesity was an independent predictor of OT >90 (odds ratio [OR] 2.02; 95% confidence interval [95% CI] 1.55-2.63), and DOAn >140 minutes (OR 1.86; 95% CI 1.42-2.43).

CONCLUSIONS

Obesity is an independent risk factor for increased OT in children undergoing LC. Pediatric surgeons and anesthesiologists should be prepared for the technical and physiological challenges that obesity may pose in this patient population.

Teaching surgery takes time: the impact of surgical education on time in the operating room

BACKGROUND

It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals.

METHODS

This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration.

RESULTS

Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%-24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals.

CONCLUSION

Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies.

Residents' scholarly activity: a cost analysis with regard to its effects on departments

PURPOSE OF REVIEW

Current financial strain on training departments may have a significantly negative impact on continuing support for residents' scholarly activity. A cost analysis with regard to residents' scholarly activity effects on anesthesiology training departments is performed.

RECENT FINDINGS

The Accreditation Council for Graduate Medical Education has issued a new outcome-focused scholarly activity requirement. Low scholarly achievement by anesthesiology faculty in the USA has been documented and needs transformation. It is evident that a structured scholarly activity support system is effective. To support such a system, training departments need to support anesthesiology residents' nonclinical time, which would cost an average of $13,500 per month per resident using nonresident hands-on care providers in operating rooms, resident's meeting attendance in average $1,424 per resident per meeting, and faculty mentorship and other infrastructure. It must also be taken into account that missed clinical opportunities by an anesthesiology resident during nonclinical time are an estimated average of 60 cases per month.

SUMMARY

The importance of resident scholarly activity has never been so or as critical as in the present. Anesthesiology leadership must continue to invest to support resident scholarly activity for the future of the specialty while being mindful of costs incurred.