Search

Background: Surgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability., Methods: Our survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts., Results: We received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes., Conclusion: Surgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons' attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice., (© 2024. The Author(s).)

Introduction: Burnout in medicine is an epidemic, and surgeons are not immune. Studies often focus on negative factors leading to burnout, with less emphasis on optimizing joy. The purpose of this study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, was to explore how gender may influence surgeon well-being to better inform organizational change., Methods: The study team developed a survey with the domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. The survey was emailed to 5777 addresses on the SAGES distribution list. Results were analyzed by calculating summary statistics., Results: 223 surgeons completed the survey; 62.3% identified as men, 32.3% as women, and 5.4% did not indicate gender. Female compared to male respondents were younger (41.6 vs 52.5 years) and had practiced for fewer years (8.4 vs 19.4 years). The three greatest differences in facilitators of joy were being a leader in the field, leading clinical teams, and teaching, with a > 10 percentage point difference between men/women rating these highly (score of ≥ 8). Women generally perceived less support from their institutions than men. The greatest gender difference was in support for teaching, with 52.8% of men rating this highly compared to 30.2% of women. Only 52% of women felt respected by coworkers most of the time compared to 68.3% of men. Most (96.0%) respondents (men 95.7% and women 98.6%) reported wanting more time with family and friends., Conclusion: This study demonstrates the complexity of the personal and professional factors that influence joy in surgery, highlight gender differences that impact joy and suggests opportunities for improved gender-based support. These results can inform potential organization-level changes and further research to better understand emerging differences in joy across gender identities., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Burnout is a crisis in medicine, and especially in surgery it has serious implications not only for physician well-being but also for patient outcomes. This study builds on previous SAGES Reimagining the Practice of Surgery Task Force work to better understand how organizations might intervene to increase the "joy in surgery.", Methods: This was a cross-sectional, descriptive study utilizing a REDCap survey with closed-ended questions for data collection across 5 domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. We calculated average scores and "percentage of respondents giving a high score" for each item., Results: There were 307 individuals who started the survey; 223 completed it and were surgeons who met the inclusion criteria. The majority (85.7%) were trained in general surgery, regardless of sub-specialty. Surgeons found joy in operating and its technical skills, curing disease, patient relationships, and working with a good team. They reported usually having what they needed to deliver care. A majority felt valued and respected. Most were dissatisfied with reimbursement, perceiving it as unfair. The most commonly worked range of hours was 51-70 per week. They reported having little time for paperwork and documentation, and if they had more time, they would spend it with friends and family., Conclusion: Organizations should consider interventions to address the operative environment, provide appropriate staff support, and foster good teamwork. They can also consider interventions that alleviate time pressures and administrative burden while at the same time promoting sustainable workloads., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Reducing costs and carbon footprints are important, parallel priorities for the US health-care system. Within surgery, reducing the number of instruments that are sterilized and disposable supplies that are used for each operation may help achieve both goals. We wanted to measure the existing variability in surgical instrument and supply choices and assess whether standardization could have a meaningful cost and environmental impact., Methods: We analyzed surgeon preference cards for common general surgery operations at our hospital to measure the number of sterilizable instrument trays and supplies used by each surgeon for each operation. From this data, we calculated supply costs, carbon footprint, and median operative time and studied the variability in each of these metrics., Results: Among the ten operations studied, variability in sterilizable instrument trays requested on surgeon preference cards ranged from one to eight. Variability in disposable supplies requested ranged from 17 to 45. Variability in open supply costs ranged from $104 to $4184. Variability in carbon footprint ranged from 17 to 708 kg CO 2 e. If the highest-cost surgeon for each operation switched their preference card to that of the median-cost surgeon, $245,343 in open supply costs and 41,708 kg CO 2 e could be saved., Conclusions: There is significant variability in the instrument and supply choices of surgeons performing common general surgery operations. Standardizing this variability may lead to meaningful cost savings and carbon footprint reduction, especially if scaled across the entire health system., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery., Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update., Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee., Results: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee., Conclusions: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Continuing Professional Development opportunities for lifelong learning are fundamental to the acquisition of surgical expertise. However, few opportunities exist for longitudinal and structured learning to support the educational needs of surgeons in practice. While peer-to-peer coaching has been proposed as a potential solution, there remains significant logistical constraints and a lack of evidence to support its effectiveness. The purpose of this study is to determine whether the use of remote videoconferencing for video-based coaching improves operative performance., Methods: Early career surgeon mentees participated in a remote coaching intervention with a surgeon coach of their choice and using a virtual telestration platform (Zoom Video Communications, San Jose, CA). Feedback was articulated through annotating videos. The coach evaluated mentee performance using a modified Intraoperative Performance Assessment Tool (IPAT). Participants completed a 5-point Likert scale on the educational value of the coaching program., Results: Eight surgeons were enrolled in the study, six of whom completed a total of two coaching sessions (baseline, 6-month). Subspecialties included endocrine, hepatopancreatobiliary, and surgical oncology. Mean age of participants was 39 (SD 3.3), with mean 5 (SD 4.1) years in independent practice. Total IPAT scores increased significantly from the first session (mean 47.0, SD 1.9) to the second session (mean 51.8, SD 2.1), p = 0.03. Sub-category analysis showed a significant improvement in the Advanced Cognitive Skills domain with a mean of 33.2 (SD 2.5) versus a mean of 37.0 (SD 2.4), p < 0.01. There was no improvement in the psychomotor skills category. Participants agreed or strongly agreed that the coaching programs can improve surgical performance and decision-making (coaches 85%; mentees 100%)., Conclusion: Remote surgical coaching is feasible and has educational value using ubiquitous commercially available virtual platforms. Logistical issues with scheduling and finding cases aligned with learning objectives continue to challenge program adoption and widespread dissemination., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: There has been considerable research into burnout but much less into how surgeons thrive and find joy. This study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, explored factors influencing surgeon well-being, the eventual goal being translating findings into tangible changes to help restore the joy in surgery., Methods: This was a qualitative, descriptive study. Purposive sampling ensured representation across ages, genders, ethnicities, practice types, and geographies. Semi-structured interviews were recorded and transcribed. We coded inductively, finalized the codebook by consensus, and then constructed a thematic network. Global themes formed our conclusions; organizing themes gave additional detail. Analysis was facilitated by NVivo., Results: We interviewed 17 surgeons from the US and Canada. Total interview time was 15 hours. Our global and organizing themes were: Stressors (Work-life Integration, Administration-related Concerns, Time and Productivity Pressures, Operating Room Factors, and Lack of Respect). Satisfaction (Service, Challenge, Autonomy, Leadership, and Respect and Recognition). Support (Team, Personal Life, Leaders, and Institutions). Values (Professional and Personal). Suggestions (Individual, Practice, and System level). Values, stressors, and satisfaction influenced perspectives on support. Experiences of support shaped suggestions. All participants reported stressors and satisfiers. Surgeons at all stages enjoyed operating and being of service. Supports and suggestions included compensation and infrastructure, but human resources were most critical. To experience joy, surgeons needed high-functioning clinical teams, good leaders/mentors, and supportive family/social networks., Conclusions: Our results indicated organizations could (1) better understand surgeons' values, like autonomy; (2) provide more time for satisfiers, like patient relationship building; (3) minimize stressors, like time and financial pressures; and (4) at all levels focus on (4a) building teams and leaders and (4b) giving surgeons time and space for healthy family/social lives. Next steps include developing an assessment tool for individual institutions to build "joy improvement plans" and to inform surgical associations' advocacy efforts., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To gather validity evidence supporting the use and interpretation of scores from the American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA) Program., Summary and Background Data: ACS ERRA is an online formative assessment program developed to assess entering surgery residents' ability to make critical clinical decisions, and includes 12 clinical areas and 20 topics identified by a national panel of surgeon educators and residency program directors., Methods: Data from 3 national testing administrations of ACS ERRA (2018-2020) were used to gather validity evidence regarding content, response process, internal structure (reliability), relations to other variables, and consequences., Results: Over the 3 administrations, 1975 surgery residents participated from 125 distinct residency programs. Overall scores [Mean = 64% (SD = 7%)] remained consistent across the 3 years ( P = 0.670). There were no significant differences among resident characteristics (gender, age, international medical graduate status). The mean case discrimination index was 0.54 [SD = 0.15]. Kappa inter-rater reliability for scoring was 0.87; the overall test score reliability (G-coefficient) was 0.86 (Ф-coefficient = 0.83). Residents who completed residency readiness programs had higher ACS ERRA scores (66% versus 63%, Cohen's d = 0.23, P < 0.001). On average, 15% of decisions made (21/140 per test) involved potentially harmful actions. Variability in scores from graduating medical schools (7%) carried over twice as much weight than from matched residency programs (3%)., Conclusions: ACS ERRA scores provide valuable information to entering surgery residents and surgery program directors to aid in development of individual and group learning plans., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Many surgical adverse events, such as bile duct injuries during laparoscopic cholecystectomy (LC), occur due to errors in visual perception and judgment. Artificial intelligence (AI) can potentially improve the quality and safety of surgery, such as through real-time intraoperative decision support. GoNoGoNet is a novel AI model capable of identifying safe ("Go") and dangerous ("No-Go") zones of dissection on surgical videos of LC. Yet, it is unknown how GoNoGoNet performs in comparison to expert surgeons. This study aims to evaluate the GoNoGoNet's ability to identify Go and No-Go zones compared to an external panel of expert surgeons., Methods: A panel of high-volume surgeons from the SAGES Safe Cholecystectomy Task Force was recruited to draw free-hand annotations on frames of prospectively collected videos of LC to identify the Go and No-Go zones. Expert consensus on the location of Go and No-Go zones was established using Visual Concordance Test pixel agreement. Identification of Go and No-Go zones by GoNoGoNet was compared to expert-derived consensus using mean F1 Dice Score, and pixel accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)., Results: A total of 47 frames from 25 LC videos, procured from 3 countries and 9 surgeons, were annotated simultaneously by an expert panel of 6 surgeons and GoNoGoNet. Mean (± standard deviation) F1 Dice score were 0.58 (0.22) and 0.80 (0.12) for Go and No-Go zones, respectively. Mean (± standard deviation) accuracy, sensitivity, specificity, PPV and NPV for the Go zones were 0.92 (0.05), 0.52 (0.24), 0.97 (0.03), 0.70 (0.21), and 0.94 (0.04) respectively. For No-Go zones, these metrics were 0.92 (0.05), 0.80 (0.17), 0.95 (0.04), 0.84 (0.13) and 0.95 (0.05), respectively., Conclusions: AI can be used to identify safe and dangerous zones of dissection within the surgical field, with high specificity/PPV for Go zones and high sensitivity/NPV for No-Go zones. Overall, model prediction was better for No-Go zones compared to Go zones. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle-income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted., Study Design: The American College of Surgeons Operation Giving Back, in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within 5 domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback., Results: One-hundred sixty-six responses were received after 3 calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development., Conclusions: This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Limitations in surgical simulation training include lack of access to validated training programs with continuous year-round training and lack of experts' ongoing availability for feedback. A model of simulation training was developed to address these limitations. It incorporated basic and advanced laparoscopic skills curricula from a previously validated program and provided instruction through a digital platform. The platform allowed for remote and asynchronous feedback from a few trained instructors. The instructors were continuously available and provided personalized feedback using a variety of different media. We describe the upscaling of this model to teach trainees at fourteen centers in eight countries., Methods: Institutions with surgical programs lacking robust simulation curricula and needing instructors for ongoing education were identified. The simulation centers ("skills labs") at these sites were equipped with necessary simulation training hardware. A remote training-the-administrators (TTA) program was developed where personnel were trained in how to manage the skills lab, schedule trainees, set up training stations, and use the platform. A train-the-trainers (TTT) program was created to establish a network of trained instructors, who provided objective feedback through the platform remotely and asynchronously., Results: Between 2019 and 2022, seven institutions in Chile and one in each of the USA, Bolivia, Brazil, Ecuador, El Salvador, México, and Perú implemented a digital platform-based remote simulation curriculum. Most administrators were not physicians (19/33). Eight Instructors were trained with the TTT program and became active proctors. The platform has been used by 369 learners, of whom 57% were general surgeons and general surgery residents. A total of 6729 videos, 28,711 feedback inputs, and 233.7 and 510.2 training hours in the basic and advanced programs, respectively, were registered., Conclusion: A remote and asynchronous method of giving instruction and feedback through a digital platform has been effectively employed in the creation of a robust network of continuous year-round simulation-based training in laparoscopy. Training centers were successfully run only with trained administrators to assist in logistics and setup, and no on-site instructors were necessary., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice., Methods: Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization., Results: Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety., Conclusions: In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Three tracks prepare Hepato-Pancreato-Biliary (HPB) surgeons: HPB, surgical oncology, and transplant fellowships. This study explored how surgical leaders thought about HPB surgery and evaluated potential candidates for HPB positions., Methods: This descriptive qualitative study utilized interviews of healthcare leaders whose responsibilities included hiring HPB surgeons. We coded inductively then used thematic network analysis to organize the data. Individual codes formed basic themes, then larger secondary themes, then finally "primary" themes., Results: Primary themes were: (1) What defines an HPB surgical practice?, (2) How do they assess candidates for HPB positions?, and (3) How will HPB practices continue to evolve? Leaders assessed applicants' training, behaviors and cultural fit, technical excellence, and more. Personal recommendations and professional networks significantly influenced the hiring process. HPB surgery needs were growing due to population changes, treatments advances, and changing market conditions., Discussion: Surgical societies should focus on facilitating networking, promoting transparency, sharing quality data, providing evidence of technical skills and teamwork, mentorship, and providing guidance to general surgery residency program directors. There is great interest in unification and cooperation across the profession, protocol standardization enhancing quality, continued workforce diversification, and evaluation of the alignment between training and practice., (Copyright © 2022 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: To establish expert consensus regarding the domains and topics for senior surgery residents (PGY-4) to make critical decisions and assume senior-level responsibilities, and to develop the formative American College of Surgeons Senior Resident Readiness Assessment (ACS SRRA) Program., Design: The American College of Surgeons (ACS) education leadership team conducted a focus group with surgical experts to identify the content for an assessment tool to evaluate senior residents' readiness for their increased levels of responsibility. After the focus group, national experts were recruited to develop consensus on the topics through three rounds of surveys using Delphi methodology. The Delphi participants rated topics using Likert-type scales and their comments were incorporated into subsequent rounds. Consensus was defined as ≥ 80% agreement with internal-consistency reliability (Cronbach's alpha) ≥ 0.8. In a stepwise fashion, topics that did not achieve consensus for inclusion were removed from subsequent survey rounds., Setting: The surveys were administered via an online questionnaire., Participants: Twelve program directors and assistant program directors made up the focus group. The 39 Delphi participants represented seven different surgical subspecialties and were from diverse practice settings. The median length of experience in general surgery resident education was 20 years (IQR 14.3-30.0) with 64% of the experts being either current or past general surgery residency program directors., Results: The response rate was 100% and Cronbach's alpha was ≥ 0.9 for each round. The Delphi participants contributed a large number of comments. Of the 201 topics that were evaluated initially, 120 topics in 25 core clinical areas were included to create the final domains of ACS SRRA., Conclusions: National consensus on the domain of the ACS SRRA has been achieved via the modified Delphi method among expert surgeon educators. ACS SRRA will identify clinical topics and areas in which each senior resident needs improvement and provide data to residents and residency programs to develop individualized learning plans. This would help in preparing the senior residents to assume their responsibilities and support their readiness for future fellowship training or surgical practice., Competing Interests: Declarations of Interest None., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: The increase in minimally invasive surgical procedures has eroded exposure of general surgery residents to open operations. High-fidelity simulation, together with deliberate instruction, is needed for advanced open surgical skill (AOSS) development., Objective: To collect validity evidence for AOSS tools to support a shared model for instruction., Design, Setting, and Participants: This prospective cohort study included postresidency surgeons (PRSs) and second-year general surgery residents (R2s) at a single academic medical center who completed simulated tasks taught within the AOSS curriculum between June 1 and October 31, 2021., Exposures: The AOSS curriculum includes 6 fine-suture and needle handling tasks, including deep suture tying (with and without needles) and continuous suturing using the pitch-and-catch and push-push-pull techniques (both superficial and deep). Teaching and assessment are based on specific microskills using a 3-dimensional printed iliac fossa model., Main Outcomes and Measures: The PRS group was timed and scored (5-point Likert scale) on 10 repetitions of each task. Six months after receiving instruction on the AOSS tasks, the R2 group was similarly timed and scored., Results: The PRS group included 14 surgeons (11 male [79%]; 8 [57%] attending surgeons) who completed the simulation; the R2 group, 9 surgeons (5 female [55%]) who completed the simulation. Score and time variability were greater for the R2s compared with the PRSs for all tasks. The R2s scored lower and took longer on (1) deep pitch-and-catch suturing (69% of maximum points for a mean [SD] of 142.0 [31.7] seconds vs 77% for a mean [SD] of 95.9 [29.4] seconds) and deep push-push-pull suturing (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 85% for a mean [SD] of 141.4 [29.1] seconds) relative to the corresponding superficial tasks; (2) suture tying with a needle vs suture tying without a needle (74% of maximum points for a mean [SD] of 64.6 [19.8] seconds vs 90% for a mean [SD] of 54.4 [15.6] seconds); and (3) the deep push-push-pull vs pitch-and-catch techniques (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 69% of maximum points for a mean [SD] of 142.0 [31.7] seconds). For the PRS group, time was negatively associated with score for the 3 hardest tasks: superficial push-push-pull (ρ = 0.60; P = .02), deep pitch-and-catch (ρ = 0.73; P = .003), and deep push-push-pull (ρ = 0.81; P < .001). For the R2 group, time was negatively associated with score for the 2 easiest tasks: suture tying without a needle (ρ = 0.78; P = .01) and superficial pitch-and-catch (ρ = 0.79; P = .01)., Conclusions and Relevance: The findings of this cohort study offer validity evidence for a novel AOSS curriculum; reveal differential difficulty of tasks that can be attributed to specific microskills; and suggest that position on the surgical learning curve may dictate the association between competency and speed. Together these findings suggest specific, actionable opportunities to guide instruction of AOSS, including which microskills to focus on, when individual rehearsal vs guided instruction is more appropriate, and when to focus on speed.

Background: Previous reports suggest that structured training in minimally invasive pancreatic surgery (MIPS) can ensure a safe implementation into standard practice. Although some training programs have been constructed, worldwide consensus on fundamental items of these training programs is lacking. This study aimed to determine items for a structured MIPS training program using the Delphi consensus methodology., Study Design: The study process consisted of 2 Delphi rounds among international experts in MIPS, identified by a literature review. The study committee developed a list of items for 3 key domains of MIPS training: (1) framework, (2) centers and surgeons eligible for training, and (3) surgeons eligible as proctor. The experts rated these items on a scale from 1 (not important) to 5 (very important). A Cronbach's α of 0.70 or greater was defined as the cut-off value to achieve consensus. Each item that achieved 80% or greater of expert votes was considered as fundamental for a training program in MIPS., Results: Both Delphi study rounds were completed by all invited experts in MIPS, with a median experience of 20 years in MIPS. Experts included surgeons from 31 cities in 13 countries across 4 continents. Consensus was reached on 38 fundamental items for the framework of training (16 of 35 items, Cronbach's α = 0.72), centers and surgeons eligible for training (19 of 30 items, Cronbach's α = 0.87), and surgeons eligible as proctor (3 of 10 items, Cronbach's α = 0.89). Center eligibility for MIPS included a minimum annual volume of 10 distal pancreatectomies and 50 pancreatoduodenectomies., Conclusion: Consensus among worldwide experts in MIPS was reached on fundamental items for the framework of training and criteria for participating surgeons and centers. These items act as a guideline and intend to improve training, proctoring, and safe worldwide dissemination of MIPS., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC)., Summary Background Data: Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively., Methods: Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by 4 high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection- over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation., Results: AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions, and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20). and 0.94 (±0.03), respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21), and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder, and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19), and 0.65 (±0.22), respectively., Conclusions: AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events., Competing Interests: Conflicts of Interest and Source of Funding: There were no sources of funding for this manuscript. D.A. is a consultant for Johnson & Johnson Institute, Verily Life Sciences, Worrell, and Mosaic Research Management. D.A. and A.N.W. have received grant funding from Olympus. A.O. has received honoraria for speaking and teaching from Medtronic, Ethicon, and Merck. A.A. is a consultant for Johnson & Johnson Institute. The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is a growing deficit of rural surgeons, and preparation to meet this need is inadequate. More research into stratifying factors that specifically influence choice in rural versus urban practice is needed., Methods: An institutional review board-approved survey related to factors influencing rural practice selection and increasing rural recruitment was distributed through the American College of Surgeons. The results were analyzed descriptively and thematically., Results: Of 416 respondents (74% male), 287 (69%) had previous rural experience. Of those, 71 (25%) did not choose rural practice; lack of professional or hospital support (30%) and lifestyle (26%) were the primary reasons. A broad scope of practice was most important among surgeons (52%), who chose rural practice without any previous rural experience. Over 60% of urban practitioners agreed that improved lifestyle and financial advantages would attract them to rural practice. The thematic analysis suggested institutional support, affiliation with academic institutions, and less focus on subspecialty fellowship could help increase the number of rural surgeons., Conclusions: Many factors influence surgeons' decisions on practice location. Providing appropriate hospital support in rural areas and promoting specific aspects of rural practice, including broad scope of practice to those in training could help grow interest in rural surgery. Strong collaboration with academic institutions for teaching, learning, and mentoring opportunities for rural surgeons could also lead to higher satisfaction, security, and potentially higher retention rate. These results provide a foundation to help focus specific efforts and resources in the recruitment and retention of rural surgeons., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Burnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout., Methods: SAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout., Results: Burnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint-including coping mechanisms, problem solving, and identification of a physician having wellness difficulties-offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers., Conclusion: Surgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.

Background: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recently developed and announced its Masters Program that aims to address existing needs of practicing surgeons for lifelong learning and consists of eight clinical pathways each containing three anchoring procedures. The objective of this study was to select the seminal articles for each anchoring procedure of these pathways using a systematic methodology., Methods: A systematic literature search of Web of Science was conducted for the most cited articles for each of the anchoring procedures of the SAGES Masters pathways. The most relevant identified articles were then reviewed by expert members of the relevant SAGES pathway committees and task forces and the seminal articles chosen for each anchoring procedure using expert consensus., Results: 578 highly cited articles were identified by the original search of the literature and the seminal articles were selected for each anchoring procedure after expert review and consensus. Articles address procedural outcomes, disease pathophysiology, and surgical technique and are presented in this paper., Conclusions: We have identified seminal articles for each anchoring procedure of the SAGES Masters program pathways using a systematic methodology. These articles provide surgeon participants of this program with a great resource to improve their procedure-specific knowledge and may further benefit the larger surgical community by focusing its attention to must-read impactful work that may inform best practices.

Background: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons., Methods: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed., Results: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures., Conclusions: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Training future rural surgeons is critical, but training needs are unclear. We hypothesize perspectives on necessity of subspecialty training differ among rural surgeons by generational cohort., Methods: An online survey was sent to ACS Rural Surgery Listserv subscribers. Closed-ended elements were analyzed using bivariate testing and logistic regression. Purposively-sampled respondents participated in qualitative interviews analyzed using principles of grounded theory., Results: Generation was irrelevant to respondents' hiring preferences, but older surgeons were more likely to state subspecialty training was ideal for any future rural surgeon. Controlling for practice context, younger rural surgeons were less likely to favor hiring a subspecialty-trained surgeon (p = 0.019). Themes emerged from qualitative analysis emphasizing broad training and the importance of practice context., Conclusion: Across generations, rural surgeons' perceptions about the training needed for rural surgery are largely stable. Considering practice context will allow educators to better prepare future rural surgeons for rural practices., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study., Methods: Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions., Results: 40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR., Conclusion: SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Evaluate the current status of Hepatopancreatobiliary (HPB) Surgery workforce in North America., Background: HPB fellowships have proliferated, with HPB surgeons entering the field through 3 pathways: transplant surgery, surgical oncology, or HPB surgery training. Impact of this growth is unknown., Methods: An anonymous survey was distributed to 654 is used as HPB surgeons from October 2012 to January 2013. Questions evaluated satisfaction with job availability after training and description of current practice. Nationwide Inpatient Sample (NIS) data from 2003 to 2010 was queried to describe the growth of HPB cases in the United States; these data were compared to prior HPB workforce projections performed using 2003 NIS data., Results: A total of 416 HPB surgeons responded (66%). HPB surgeons are concentrated in a small number of states/provinces with a lack of HPB surgeon workforce in central United States. HPB graduates from 2008 to 2012 report increased difficulty in identifying an HPB-focused practice versus prior to 2008. Mature HPB surgery practices report a composition of 25% to 50% non-HPB operative cases. Fifty-one percent of respondents reported an opinion that current HPB Surgeon production was excessive; however, 2010 NIS data demonstrate that major HPB surgery cases have grown significantly more than was previously projected using 2003 NIS data., Conclusions and Relevance: A cohesive strategy for responsibly responding to the HPB surgical workforce requirements of North America is needed. Elevation of training standards, standardization of requirements for certification, and careful modeling that accounts for regionalization of care should be pursued to prevent overtraining and decentralization of HPB surgical care in the future.

Background: Hepatopancreatobiliary (HPB) surgery fellowship training has multiple paths. Prospective trainees and employers must understand the differences between training pathways. This study examines self-reported fellowship experiences and current scope of practice across three pathways., Methods: An online survey was disseminated to 654 surgeons. These included active Americas Hepato-Pancreato-Biliary Association (AHPBA) members and recent graduates of HPB, transplant-HPB and HPB-heavy surgical oncology fellowships., Results: A total of 416 (64%) surgeons responded. Most respondents were male (89%) and most were practising in an academic setting (83%). 290 (70%) respondents underwent formal fellowship training. Although fellowship experiences varied, current practice was largely similar. Minimally invasive surgery (MIS) and ultrasound were the most commonly identified areas of training deficiencies and were, respectively, cited as such by 47% and 34% of HPB-, 49% and 50% of transplant-, and 52% and 25% of surgical oncology-trained respondents. Non-HPB cases performed in current practice included gastrointestinal (GI) and general surgery cases (56% and 49%, respectively) for HPB-trained respondents, transplant and general surgery cases (87% and 21%, respectively) for transplant-trained respondents, and GI surgery and non-HPB surgical oncology cases (70% and 28%, respectively) for surgical oncology-trained respondents., Conclusions: Fellowship training in HPB surgery varies by training pathway. Training in MIS and ultrasound is deficient in each pathway. The ultimate scope of non-transplant HPB practice appears similar across training pathways. Thus, training pathway choice is best guided by the training experience desired and non-HPB components of anticipated practice., (© 2015 International Hepato-Pancreato-Biliary Association.)

Simple Summary: Despite the potential of fluorescence imaging during pancreatic cancer surgery, more research is needed to facilitate the approval of tumor-targeted probes, standardize imaging techniques, and most importantly, gain trust from surgeons. Despite advancements in the development of novel probes, preclinical research settings do not always accurately represent the surgical setting. This first-of-its-kind Delphi consensus survey highlights current experiences and attitudes towards fluorescence imaging during pancreatic cancer surgery, specifically from surgeon's perspectives. The results from this consensus survey highlight potential new directions for future research, which could facilitate the standardized use of fluorescence imaging during pancreatic surgery. Indocyanine green (ICG) is one of the only clinically approved near-infrared (NIR) fluorophores used during fluorescence-guided surgery (FGS), but it lacks tumor specificity for pancreatic ductal adenocarcinoma (PDAC). Several tumor-targeted fluorescent probes have been evaluated in PDAC patients, yet no uniformity or consensus exists among the surgical community on the current and future needs of FGS during PDAC surgery. In this first-published consensus report on FGS for PDAC, expert opinions were gathered on current use and future recommendations from surgeons' perspectives. A Delphi survey was conducted among international FGS experts via Google Forms. Experts were asked to anonymously vote on 76 statements, with ≥70% agreement considered consensus and ≥80% participation/statement considered vote robustness. Consensus was reached for 61/76 statements. All statements were considered robust. All experts agreed that FGS is safe with few drawbacks during PDAC surgery, but that it should not yet be implemented routinely for tumor identification due to a lack of PDAC-specific NIR tracers and insufficient evidence proving FGS's benefit over standard methods. However, aside from tumor imaging, surgeons suggest they would benefit from visualizing vasculature and surrounding anatomy with ICG during PDAC surgery. Future research could also benefit from identifying neuroendocrine tumors. More research focusing on standardization and combining tumor identification and vital-structure imaging would greatly improve FGS's use during PDAC surgery. [ABSTRACT FROM AUTHOR]

Objective: The Accreditation Council for Graduate Medical Education (ACGME) has challenged program directors to assess their residents'' core competencies, including communication and interpersonal skills (CIS). We report our institution''s experience using a series of standardized patient encounters in an objective structured clinical examination (OSCE) to evaluate CIS in surgical residents.Methods: Standardized patients rated the residents'' ability to maintain a patient-centered approach across 6 challenging communication tasks. Residents received verbal feedback from the patients after each encounter and completed a survey indicating their experience and comfort with each task. Individual and group reports documented resident competency and provided aggregate information for curriculum review. Formal grades were not assigned.Results: Twenty-two residents in 2 surgical residency programs piloted the assessment. The Generalizability of the assessment was 0.81. Scores of second- and third-year residents were not significantly different. Residents found the program to be helpful and able to assess their skills.Conclusions: The standardized patient-based OSCE is an effective method to assess communication and interpersonal skills and provides useful information for curriculum review. [Copyright &y& Elsevier]

In this article, the author discusses the important contribution of a trial on the efficacy of stapler versus hand-sewn closure in the problem of distal pancreatectomy. He mentions that the trial's leadership should be recommended for their ability to influence experienced surgeons to join. He states that the trial's design and consensus definition permit surgeons in understanding the disease process' natural history and to equate innovations more exactly between the trial and future trials.