Search

Background As operating room (OR) expenditures increase, faculty and surgical trainees will play a key role in curbing future costs. However, supply cost utilization varies widely among providers and, despite requirements for cost education during surgical training, little is known about trainees' comfort discussing these topics. To improve OR cost transparency, our institution began delivering real-time supply “receipts” to faculty and trainees after each surgical case. This study compares faculty and surgical trainees' perceptions about supply receipts and their effect on individual practice and cultural change. Study Design Faculty and surgical trainees (residents and fellows) from all adult surgical specialties at a large academic center were emailed separate surveys. Results A total of 120 faculty (30.0% response rate) and 119 trainees (35.7% response rate) completed the survey. Compared with trainees, faculty are more confident discussing OR costs (p Conclusions Supply receipts have been well received and have led to meaningful cultural changes. However, trainees are less confident discussing these issues and desire a greater emphasis on OR cost in their curriculum.

Background The COVID-19 pandemic travel restrictions triggered a rapid alteration in the interview process for fellowships this spring. We describe our initial experience with virtual interviews for Advanced GI Minimally Invasive Surgery Fellowships and assess the value and limitations via a post-interview applicant survey. Study Design Twenty candidates were interviewed via Zoom teleconferencing March-April 2020 using combined group and breakout rooms. An anonymous post-interview Likert and free text survey was sent to candidates with questions regarding feasibility, appropriateness, and acceptability of this method. Results Seventeen of 20 candidates (85%) responded to the survey. The candidates rated ease of interaction with the program director, faculty surgeons, and the current fellow highly: 94%, 83%, and 89%, respectively. The majority (53%) stated the virtual interviews exceeded or met expectations. Only a minority, 12%, reported the virtual platform was short of expectations. Approximately 70% noted little to no impact of not being able to conduct these interviews in-person and not being able to physically see the program institution. Overall, 94% were satisfied with their experience, and only 6% were neutral with no respondents reporting dissatisfaction. Finally, 76% would recommend a virtual interview in the future. Most negative open response comments were secondary to issues with software rather than the lack of the in-person traditional interviews. Conclusions The use of a remote teleconferencing platform provides a favorable method for conducting fellowship interviews and results in a high degree of candidate satisfaction. Virtual interviews will likely be increasingly substituted for in-person interviews across the spectrum of medical training., The COVID-19 pandemic triggered rapid alteration of the fellowship interview process. In response, we conducted remote virtual interviews via Zoom software platform and anonymously surveyed the applicants. Our experience demonstrates a feasible and favorable alternative or adjunct to traditional in-person interviews.

Background With an array of hernia meshes with varying properties, intraoperative decision making for the optimal mesh is critical. Although meshes are subjected to regulatory review through the Food and Drug Administration, it is unknown whether mesh properties are visually accessible. To facilitate greater knowledge for the surgeon on mesh choice, we aimed to comprehensively analyze hernia mesh packaging and regulations. Study Design Labeling guidelines and 510(k) requirements across Food and Drug Administration-regulated products were analyzed and compared with mesh packaging. Packages and Instructions for Use were analyzed for commonly available hernia meshes. Literature review was conducted to understand recommended guidelines for mesh products. A novel hernia mesh packaging label was designed to rectify under-reporting. Results We found that food labels undergo critical scrutiny and detailed specifications, yet medical devices are not subjected to similar guidelines. The highest reported property on packages was the presence of a barrier (80%), and the lowest reported property was barrier composition (33%). For Instructions for Use, the lowest reported properties were mechanics (31%) and thickness (11%), both of which were not reported on packaging. Descriptive terms for pore size and mechanics were reported inconsistently. To overcome this under-reporting of properties, we propose a novel packaging label with properties chosen from regulatory guidelines, packaging analysis, and literature review. Conclusions Although standardized terminology has been proposed in literature, property knowledge has not adequately permeated surgery, industry, or regulatory guidelines. There is extreme under-reporting and lack of consistency of clinically important mesh properties. Standardized packaging labels will provide accessibility of these properties and aim to bring standardized terminology into practice. With an increase in access to important properties, this can facilitate intraoperative decision making on a case-by-case basis.

Background With the epidemic of prescription opioid abuse in the US, rates of opioid-related unintentional deaths have risen dramatically. However, few data exist comparing postoperative opioid prescriptions with patient use. We sought to better elucidate this relationship in surgical patients. Study Design A prospective cohort study was conducted of narcotic-naive patients undergoing open and laparoscopic abdominal procedures on a minimally invasive surgery service. During the first 14 post-discharge days and at their first postoperative clinic visit, patients recorded pain scores and number of opioid pills taken. Clinical data were extracted from the medical record. Descriptive statistics were used in data analysis. Results From 2014 through 2017, one hundred and seventy-six patients completed postoperative pain surveys. Mean age was 60.4 ± 14.9 years and sex was distributed equally. Most patients (69.9%) underwent laparoscopic procedures. Hydrocodone-acetaminophen was the most commonly prescribed postoperative pain medication (118 patients [67.0%]), followed by oxycodone-acetaminophen (26 patients [14.8%]). Patients were prescribed a median of 150 morphine milligram equivalents (MME) (interquartile range [IQR] 150 to 225 MME), equivalent to twenty 5-mg oral oxycodone pills (IQR 20 to 30 pills). However, by their first postoperative visit, they had only taken a median 30 MME (IQR 10 to 90 MME), or 4 pills (IQR 1.3 to 12 pills). Eight (4.5%) patients received a refill or an additional prescription for pain medications. At the first postoperative visit, 76.7% of respondents were satisfied or very satisfied with their overall postoperative pain management. Conclusions Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.

Background The lack of a universally accepted classification system for incisional hernia repair has led to inconsistent reporting of ventral hernia repairs, the inability to compare various series, and the lack of appropriate risk adjusted stratification systems to evaluate surgical outcomes. This study evaluates the Ventral Hernia Working Group's (VHWG) grading scale to accurately predict surgical site occurrence (SSO) after open ventral hernia repair. Study Design All open ventral hernia repairs performed at Case Medical Center were evaluated from a prospectively maintained database. Hernias were graded according to the VHWG grading scale, and patients were evaluated for the incidence of a SSO. The relationships between comorbidities, hernia defect characteristics, CDC wound classification, and SSOs were also evaluated. Results There were 299 patients who met inclusion criteria and were available for follow-up. Surgical site occurrence was identified in 14% grade 1, 29% grade 2, 38% grade 3, and 49% grade 4 patients (p = 0.003). However, grade 3 patients with only a previous wound infection had a significantly different incidence of SSO than those with a violation of the gastrointestinal (GI) tract and were actually more similar to grade 2 patients. Likewise, violation of the GI tract had a similar rate of SSO to grade 4 patients. Finally, CDC wound classification also accurately predicted SSO across all levels of contamination. Conclusions Modification of the VHWG grading scale into a 3-level grading system would significantly improve the accuracy of predicting SSO after open ventral hernia repair. Grade 2 patients should include those with comorbidities and previous wound infections. Grade 3 patients should be stratified based on CDC definitions of wound contamination. This modified grading scale would significantly improve outcomes reporting after open ventral hernia repair.

Background Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical intervention's effect on a patient's quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on abdominal wall function, evaluate its measurement properties, and assess the impact of VHR on QofL using this new instrument. Study Design A 16-question QofL survey tool, HerQLes, was constructed. Patients presenting for elective VHR completed the survey. Rasch modeling was used to evaluate the items; fit statistics, person-item mapping, separation index, and reliability were examined. Associations between baseline characteristics and QofL were assessed. Results Eighty-eight patients completed the survey before assessment for VHR. Mean age was 57.2 years (±12.4 years), mean American Society of Anesthesiologists score was 2.8 (±0.5), and mean body mass index was 34.9 kg/m 2 (±9.3 kg/m 2 ). Based on Rasch modeling, 12 of 16 items met model fit criteria. The 4 poorly fitting items were eliminated from further analysis. The 12 items retained have good internal consistency reliability (0.86). On a 0- to 100-point scale, mean QofL score was 47.2 (±15.6). Patients with higher grade hernias had lower HerQLes scores (p = 0.06). Patients showed significant improvement in abdominal wall function and QofL 6 months after VHR (p Conclusions Quality-of-life is an important component of surgical management of ventral hernias. The 12-question QofL survey, HerQLes, is reliable and valid. At baseline, patients with more complex hernias tended to have a decreased abdominal wall function and QofL. Six months after surgical repair, HerQLes scores change in the predicted direction. We believe HerQLes is potentially a valuable tool to assess patient-centered abdominal wall functional improvements after VHR.

Background The ideal technique for the use of AlloDerm (LifeCell Corp) in complicated ventral hernia repair has not been defined. The expense of these products mandates careful evaluation to justify their widespread use. We compared two techniques of fascial bridging versus fascial reinforcement repair with regard to their longterm recurrence rates using AlloDerm. Study Design We retrospectively studied patients with abdominal defects repaired with AlloDerm at our institution. Results Thirty-seven patients with abdominal wall repairs using AlloDerm were identified between January 2004 and December 2005. Eleven patients underwent bridged fascial repair; 26 patients had reinforced fascial repair. There was no statistical significance between the 2 groups in terms of average age (57 versus 52 years), body mass index (35 versus 29 kg/m2), American Society of Anesthesiologists score (2.9 versus 2.5), or number of earlier abdominal operations (3.4 versus 3.5). The average sizes of AlloDerm used were 175 cm2 for bridged and 89 cm2 for reinforced repair (p=0.005). In patients with reinforced closure, primary repair was achieved with lateral component separation in 22 of 26 patients. Mean followup was 21.4 months (range 15 to 36 months). In the bridged group, 1 patient died on postoperative day 20. Of the remaining 10 patients, 8 patients (80%) developed recurrences. Seven patients required reoperation, but one patient refused repair. In the reinforced group, four patients were lost to followup and two patients died. Four of the remaining 20 patients (20%) developed recurrences that required repair; this was significantly different from the recurrence rate in the bridged group (p=0.009). Conclusions This study demonstrated that the method in which AlloDerm is used in abdominal wall reconstruction has a significant impact on recurrence rates. Based on our findings, AlloDerm should be used only as a reinforcement after primary fascial reappoximation.