Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery

Importance

Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery.

Objectives

To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures.

Design, Setting, and Participants

A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included.

Exposure

Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair.

Main Outcomes and Measures

The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups.

Results

During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days).

Conclusions and Relevance

While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.

Palliative Care Curriculum and Training Plan for community health workers

African American patients are less likely than White patients to access palliative care. Community health workers (CHWs) are non-clinical public health workers who may address this gap. We developed a Palliative Care Curriculum and Training Plan for CHWs as part of an ongoing randomised controlled trial evaluating the effectiveness of a CHW palliative care intervention for African American patients with advanced cancer. This study aimed to determine whether the Palliative Care Curriculum and Training Plan leads to gains in knowledge, perceived competence on CHW study-based tasks, and satisfaction among CHWs. The curriculum was delivered over 3 months using synchronous, asynchronous and experiential training components. CHWs were assessed through survey questionnaires and semistructured interviews. We trained a total of three CHWs, one from each of our enrolment sites: Johns Hopkins Hospital, TidalHealth Peninsula Regional and University of Alabama at Birmingham Hospital. CHWs demonstrated an increase in knowledge, with a mean pre-training test score of 85% (SD 10.49) and post-training test score of 96% (SD 4.17). The training led to increases in perceived competence among CHWs. Areas for future training were identified. This curriculum serves as a template for CHW training focused on palliative care, oncology and health disparities.

Cross-sectional study in Madagascar demonstrates efficacy of virtual mentoring and flipped classroom modifications of neonatal resuscitation programme Helping Babies Breathe

AIM

The Covid-19 pandemic necessitated virtual adaptation of the neonatal resuscitation programme Helping Babies Breathe (HBB). This study assessed one such virtually mentored and flipped classroom modification in Madagascar.

METHODS

A cross-sectional study was performed in September 2021 and May 2022. Healthcare providers were identified by local collaborating organisations. United States-based master trainers collaborated with local trainers on virtually mentored trainings followed by independent trainings. Master trainers were available for consultation via Zoom during the virtual training. A flipped classroom modification and traditional didactic method were compared. Primary outcomes were knowledge and skill acquisition, evaluated by written assessments and objective structured clinical examinations.

RESULTS

Overall, 97 providers completed the curriculum. Written assessment scores improved in both training models (traditional - 74.8% versus 91.5%, p<0.001; flipped classroom - 89.7% versus 93.6%, p<0.05). There was no significant difference among written assessment scores (92.8% versus 91.5%, p=0.62) and significantly higher objective structured clinical examination scores (97.3% versus 89.5%, p<0.001) for the independent training compared to the virtually mentored training.

CONCLUSION

The virtually mentored HBB training was followed by a successful independent training as measured by participant knowledge and skill acquisition, supporting the efficacy of virtual dissemination.

Percutaneous Needle Biopsies of the Breast in Women Younger than 35 Years: Minimally or Excessively Invasive?

Percutaneous needle biopsy (PNB) of the breast is commonly used for diagnosis of breast pathology, but has been less studied in young women. We sought to determine the effectiveness and necessity of PNB in patients younger than 35 years of age. The charts of sequential patients <35 years who underwent PNB between February 2013 and May 2016 were reviewed; 181 PNB were performed in 127 patients. Median age was 30 years (13-34). Indications for PNB were Breast Imaging Reporting and Data System (BIRADS) ≥4 in 137 (75.7%) cases, with mass on imaging in 139 (76.8%). Carcinoma was diagnosed in 12 (6.6%), PNB in eight unique patients (6.3%). Other PNB pathology included atypia in four (2.2%) patients; papillary lesion, five (2.8%); benign lymph node, 10 (5.5%); fibroepithelial lesion, 15 (8.3%); benign breast tissue, 63 (34.8%); and fibroadenoma, 72 (39.8%). Women with atypia or malignancy were older than those with benign findings (30.9 vs 28.0 years, P = 0.002). No other patient or imaging factors were significantly associated with pathologic diagnosis on PNB. Routine PNB for all BIRADS 4 findings may be over-used in young women as most results are benign and subsequent surgical findings are concordant. Improved diagnostic accuracy of breast imaging is warranted to reduce unnecessary procedures.