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Missed diagnosis of traumatic diaphragmatic hernia is a known complication of blunt trauma as the diagnosis can be difficult to ascertain acutely. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently, open primary repair was the standard of care with few centers attempting laparoscopic repair for select patients. The objective of this study was to evaluate the safety, technical feasibility, and clinical outcomes for minimally invasive repair utilizing the DaVinci Robotic platform for traumatic diaphragmatic hernia repair. Robotic repair was performed on a patient who presented with a large diaphragmatic hernia 9 years after blunt trauma. The procedure was recorded, technique detailed, and clinical outcomes assessed. There were no significant adverse events noted. After 1 year, the patient is doing well with no complaints, no evidence of recurrence and no other complications. Robotic repair of traumatic diaphragmatic hernia effectively achieved reduction of herniated contents, primary defect closure, and broad mesh overlap with good results at 1 year. This approach may provide an innovative minimally invasive option for surgeons and patients.

Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423–430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting. We conducted a non-systematic review of the literature. Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery. SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.

Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery.Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group.A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates.SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. However, the use of LC in the emergency setting is relatively unstudied. The authors describe their experience with a series of emergent and urgent LC cases for a variety of colorectal pathologies. This study reviewed 20 consecutive patients who had a laparoscopic emergent or urgent colectomy over a 2-year period. Patient demographics, indications for surgery, operative details, and postoperative complications were examined. Two cases were converted to open procedure, and the mean operative time was 162 min (median, 163 min). The average postoperative length of hospital stay was 8.1 days (median, 6 days). There was one reoperation and three readmissions within 30 days, with no mortality during the follow-up period. Six patients required intensive care unit (ICU) stays after surgery, and 40% of the patients had one or more postoperative complications. With increasing experience, LC is a feasible option in nonelective situations. Further prospective and comparative studies will improve our understanding of the outcomes for emergency LC.