The impact of junior surgical jobs in cardiothoracic surgery on career choice in the United Kingdom

Objectives

Cardiothoracic surgery is a small specialty, often with a limited presence on the undergraduate curriculum. In the past, there was a heavy reliance on postgraduate exposure to inform career choice. Recent changes in recruitment to the specialty in the United Kingdom may reduce exposure of the best trainees to the specialty, and reduce the quality of future surgeons. This study will evaluate the impact of junior surgical jobs on future career preferences.

Methods

We asked all 126 core surgical trainees in the Northern Ireland Deanery their surgical specialty preferences over 2 years. Trainees were asked for their first and second preferences on each occasion. In total 502 first and second preferences were declared. Past and present postings were then correlated with this information to see if working in a cardiothoracic unit impacted on specialty preference choices.

Results

Cardiothoracic surgery is the least popular of all the surgical specialties amongst junior surgical trainees (3.6%)—with general surgery, breast surgery, and orthopaedic surgery, drawing 53% of trainees. In trainees who had previously worked in cardiothoracic surgery, 75% expressed a wish to return to the specialty, making it the most dominant.

Conclusions

The role of junior surgical jobs in the specialty is immensely important on career choice. Moving to a more junior recruitment may exclude excellent candidates who have simply not experienced cardiothoracic surgery.

     

Training system for laparoscopy-assisted distal gastrectomy

Purpose

Laparoscopy-assisted distal gastrectomy (LADG) is likely to become a standard procedure for gastric cancer, which highlights the importance of establishing a training system in which even inexperienced surgeons can perform this procedure safely. This study assesses our training system for LADG based on short-term surgical outcomes.

Methods

We evaluated retrospectively the short-term outcomes of 100 consecutive LADGs with curative D1/D1+ lymph node dissection. Our training system was assessed based on the learning curve of trainees, and factors related to achieving good-quality operations were analyzed statistically.

Results

Overall, postoperative complications developed in 10 patients (10%), and included one case of anastomotic leakage (1%) and one case of pancreatic fistula (1%). The learning curve of the trainees plateaued after 10 operator cases in terms of operation time. The importance of the trainer’s position was also confirmed by the result that the operation time was significantly longer when trainees with ≤10 operator cases performed LADG with a trainer as scopist vs. a trainer as the first assistant. Univariate and multivariate analyses revealed that >10 operator cases were the most important factor for achieving good-quality operations.

Conclusion

These results show that our current LADG procedure and training system are appropriate and effective.

     

LeFort colpocleisis: a step-by-step simulation video for Female Pelvic Surgeons

Introduction and hypothesis

LeFort colpocleisis is a minimally invasive surgical option for patients with pelvic organ prolapse who no longer desire sexual activity. Pelvic surgeons have limited exposure to this procedure during their training, and are therefore less likely to offer this procedure to their patients.

Methods

We use a split screen live action surgery, side by side with a low cost 3D model of a prolapse to describe a LeFort colpocleisis step by step.

Results

This video is an easily reproducible guide to the steps and surgical techniques necessary to successfully perform a LeFort colpocleisis. The simulation model can be used to educate and train those performing female pelvic surgery.

Conclusion

Pelvic surgeons should be able to offer LeFort colpocleisis to their patients. This video may be used to facilitate the understanding and reproducibility of the procedure.

     

Impact of Residency Training Level on the Surgical Quality Following General Surgery Procedures

Objective

To investigate the safety of surgical performance by residents of different training level performing common general surgical procedures.

Methods

Data were consecutively collected from all patients undergoing general surgical procedures such as laparoscopic cholecystectomy, laparoscopic appendectomy, inguinal, femoral and umbilical hernia repair from 2005 to 2011 at the Department of Surgery of the University Hospital of Zurich, Switzerland. The operating surgeons were grouped into junior residents, senior residents and consultants. The comprehensive complication index (CCI) representing the overall number and severity of all postoperative complications served as primary safety endpoint. A multivariable linear regression analysis was used to analyze differences between groups. Additionally, we focused on the impact of senior residents assisting junior residents on postoperative outcome comparing to consultants.

Results

During the observed time, 2715 patients underwent a general surgical procedure. In 1114 times, a senior resident operated and in 669 procedures junior residents performed the surgery. The overall postoperative morbidity quantified by the CCI was for consultants 5.0 (SD 10.7), for senior residents 3.5 (8.2) and for junior residents 3.6 (8.3). After adjusting for possible confounders, no difference between groups concerning the postoperative complications was detected. There is also no difference in postoperative complications detectable if junior residents were assisted by consultants then if assisted by senior residents.

Discussion

Patient safety is ensured in general surgery when performed by surgical junior residents. Senior residents are able to adopt the role of the teaching surgeon in charge without compromising patients’ safety.

     

Developing and validating a tool for measuring the educational environment in clinical anesthesia

Purpose

We aimed to develop a contemporary measure for anesthesia teaching and learning in the operating theatre that was applicable to a variety of training jurisdictions, the Measure for the Anaesthesia Theatre Educational Environment (MATE).

Methods

A systematic review of the literature and modified Delphi approach was used to identify items for content validity. Reliability and exploratory factor analyses were conducted after a pilot survey of trainees to show construct validity, with removal of redundant items. Item domains were identified through a global assessment of factor structure accuracy and relation to real-world constructs.

Results

Literature review generated an initial 73-item list. A modified Delphi approach with 24 experts identified 44 relevant items. The pilot survey generated 390 responses. Reliability analysis, exploratory factor analysis, and global assessment refined the measure to 33 items. Four domains were identified according to factor structure: teaching preparation and practice, assessment and feedback, procedures and responsibility, and overall atmosphere. The educational environment was rated by trainees at 74.6 ± 15.6% with excellent internal consistency (Cronbach’s α = 0.975).

Conclusion

The MATE survey tool generated valid and reliable scores when measuring the educational environment in the operating theatre. Further research is required to investigate possible differences between the training countries and age of junior doctors and the associated underlying factors. Other researchers are invited to administer the survey and share results within a central database.

     

Perception and Awareness of Bariatric Surgery in Canada: a National Survey of General Surgeons

Background

The objective of this study was to assess Canadian general surgeons’ knowledge of bariatric surgery and perceived availability of resources to manage bariatric surgery patients.

Methods

A self-administered questionnaire was developed using a focus group of general surgeons. The questionnaire was distributed at two large general surgery conferences in September and November 2012. The survey was also disseminated via membership association electronic newsletters in November and December 2012.

Results

One hundred sixty-seven questionnaires were completed (104 practicing surgeons, 63 general surgery trainees). Twenty respondents were bariatric surgeons. Among 84 non-bariatric surgeons, 68.3 % referred a patient in the last year for bariatric surgery, 79 % agreed that bariatric surgery resulted in sustained weight loss, and 81.7 % would consider referring a family member. Knowledge gaps were identified in estimates of mortality and morbidity associated with bariatric procedures. The majority of surgeons surveyed have encountered patients with complications from bariatric surgery in the last year. Over 50 % of surgeons who do not perform bariatric procedures reported not feeling confident to manage complications, 35.4 % reported having adequate resources and equipment to manage morbidly obese patients, and few are able to transfer patients to a bariatric center. Of the respondents, 73.3 % reported residency training provided inadequate exposure to bariatric surgery, and 85.3 % felt that additional continuing medical education resources would be useful.

Conclusions

There appears to be support for bariatric surgery among Canadian general surgeons participating in this survey. Knowledge gaps identified indicate the need for more education and resources to support general surgeons managing bariatric surgical patients.

     

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training

Background

Changes in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training.

Methods

Surgeons from various specialties were invited to attend a 1 day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons’ opinions of cadaveric simulation.

Results

According to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (p = 0.015). Thiel were found to be realistic (p < 0.001) to have reduced odour (p = 0.002) and be more cost-effective (p = 0.003). Ethical constraints were considered to be small.

Conclusion

Thiel cadavers are suitable for training in most surgical specialties.

     

Feasibility and benefits of the ewe as a model for vaginal surgery training

Introduction and hypothesis

The objective was to evaluate the ewe as an animal model for teaching and training in vaginal surgery.

Methods

Twenty-nine postgraduate surgeons attended a training course on vaginal prolapse surgery. After a review of human and sheep anatomy, the participants performed transvaginal meshes, vaginal hysterectomy, SSLF (Richter), and OAS repair in ewes and human cadavers. Participants completed questionnaires on the whole course.

Results

Questionnaires showed the significant superiority of ewes over human cadavers for all items evaluated regarding surgical dissections. Only identification of the sacrospinous ligament and the spine were judged to be similar in ewes and human cadavers. Participants noticed that ewe model is appropriate for vaginal prolapse surgery training for resident and for postgraduate surgeons. Two vaginal hysterectomies were also performed. Operating time, surgery, and anatomy were nearly identical to that of humans. The same conclusions were made while performing sacrospinous ligament fixation (Richter) and obstetric anal sphincter injury repair.

Conclusion

This series indicates that the ewe is a useful animal model for teaching vaginal surgery.

     

Eponymous terms in daily practice: a survey among Dutch orthopedic surgeons

Introduction

With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues.

Materials and methods

In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice.

Results

No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons.

Discussion

Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty.

Conclusion

Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.

     

Prospective Evaluation of Innovative Force Assessing Firmware in Simulation to Improve the Technical Competence of Surgical Trainees

Introduction

Suturing is an integral part of all surgeries. In minimal access surgery, the force exerted is based only on visual perception (tautness of the thread and degree of tissue deformation). An unbalanced suture force can cause tissue rupture or cut-through resulting in avoidable morbidity and mortality. There is a need to find ways of improving surgical dexterity and finesse without adversely affecting patient outcomes.

Aim

We aimed to calculate the knot-tying force in minimal access pancreatic surgery (MAPS) performed by experienced surgeons (ES) and use this information to develop a surgical suturing model to train the surgical trainees. We have developed a firmware for force sensor calibration and post-data analysis, using which we aimed to compare the differences in forces applied by a trainee as compared to ES.

Results

Our technology showed that, as compared to the ES, the trainee’s (TS) knot was unbalanced with significant differences in force applied per knot for each of the knots (P < 0.01). The shape of the Force curve for each suture was also different for the TS as compared to the ES. After using the training tool, the forces applied by the TS and the Force curve for the whole suture were similar to those of the ES.

Conclusion

Our firmware promises to be an excellent training tool for organ anastomosis. Considering the complexity and likely complications of MAPS, it is a sine qua non that the surgeon be highly experienced and skilled. Surgical simulation is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they can safely operate on humans.

     

The “learning curve” for retropubic mid-urethral sling procedures: a retrospective cohort study

Introduction and hypothesis

Mid-urethral tape procedures brought a paradigm shift in surgery for stress incontinence; little research into the development and maintenance of surgical competence for the procedure exists. The hypothesis behind this study is that the  “learning curve” for retropubic mid-urethral sling procedures, judged by the surrogate of bladder perforation, is longer than previously thought.

Methods

This was a retrospective single-centre database and case note review of retropubic mid-urethral tape procedures. Unadjusted rates of bladder perforation, operating time, postoperative voiding difficulty, tape extrusion, and patient reported outcome were calculated; progress was evaluated using the cumulative sum method. Outcomes were assessed for 1 consultant, 2 subspecialty trainees (fellows), 7 advanced training skills module (ATSM) trainees (senior residents) and 6 core specialty trainees (residents) in years 4–7 of training.

Results

A total of 1,568 women were identified as having mid-urethral tape procedures; 568 (36 %) had additional procedures concurrently; 259 (20 %) were secondary procedures. The overall perforation rate for individual surgeons varied between 0 and 31 % and averaged 10.3 % amongst the core and ATSM trainees (a mean of 11 procedures), 4.5 % amongst the subspecialty trainees (a mean of 66 procedures) and 1.3 % for the consultant (1,284 procedures). The number of perforations for individual surgeons peaked at between 10 and 30 procedures undertaken. The number of cases performed to reach a target level of ≤5 % perforations varied between 20 and 80.

Conclusions

Whilst seductively simple in concept, mid-urethral tape procedures are not without risk; their inherently “blind” nature makes them difficult to teach. The “learning curve” to independent practice may be longer than previously considered.

     

Ergonomics: making the OR a comfortable place

Introduction

The objective of this video is to highlight strategies to improve operating room (OR) ergonomics, which will result in increased surgeon comfort during minimally invasive gynecologic surgery and decreased risk of musculoskeletal injury.

Methods

Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons, including those who perform minimally invasive gynecologic surgery. WMSDs are repetitive strain injuries that can damage a surgeon’s muscles, nerves, and/or joints and commonly affect the neck, back, wrist, and hands. In addition to chronic pain, these injuries can lead to decreased job satisfaction and productivity.

Results

This video will discuss general ergonomic principles and demonstrate ergonomic techniques in conventional laparoscopic, vaginal, and robotic surgery.

Conclusions

Minimally invasive gynecologic surgery can be physically taxing on the surgeon. Understanding principles and utilizing techniques of OR ergonomics can minimize these physical demands and result in a long, healthy, and pain-free surgical career.

     

Efficacy of Surgical Simulation Training in a Low-Income Country

Introduction

Simulation training has evolved as an important component of postgraduate surgical education and has shown to be effective in teaching procedural skills. Despite potential benefits to low- and middle-income countries (LMIC), simulation training is predominately used in high-income settings. This study evaluates the effectiveness of simulation training in one LMIC (Rwanda).

Methods

Twenty-six postgraduate surgical trainees at the University of Rwanda (Kigali, Rwanda) and Dalhousie University (Halifax, Canada) participated in the study. Participants attended one 3-hour simulation session using a high-fidelity, tissue-based model simulating the creation of an end ileostomy. Each participant was anonymously recorded completing the assigned task at three time points: prior to, immediately following, and 90 days following the simulation training. A single blinded expert reviewer assessed the performance using the Objective Structured Assessment of Technical Skill (OSATS) instrument.

Results

The mean OSATS score improvement for participants who completed all the assessments was 6.1 points [95 % Confidence Interval (CI) 2.2–9.9, p = 0.005]. Improvement was sustained over a 90-day period with a mean improvement of 4.1 points between the first and third attempts (95 % CI 0.3–7.9, p = 0.038). Simulation training was effective in both study sites, though most gains occurred with junior-level learners, with a mean improvement of 8.3 points (95 % CI 5.1–11.6, p < 0.001). Significant improvements were not identified for senior-level learners.

Conclusion

This study supports the benefit for simulation in surgical training in LMICs. Skill improvements were limited to junior-level trainees. This work provides justification for investment in simulation-based curricula in Rwanda and potentially other LMICs.

     

Laparoscopic Appendectomy: Minimally Invasive Surgery Training Improves Outcomes in Basic Laparoscopic Procedures

Background

To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training.

Methods

Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded.

Results

A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32–60 vs. 58 min, IQR 44–81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001).

Conclusions

MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.

     

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly

Purpose

The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures.

Methods

Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences.

Results

Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon’s decision.

Conclusions

There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions.

Level of Evidence

Level III - Case controlled study

     

Versorgung von Notfallpatienten in Bedrohungslagen

Background

The increasing threat of terrorist attacks necessitates adaption of preclinical emergency medicine.

Objective

Presentation of international lessons learned, the current approach of the military and police and deductions for the German authorities and organizations.

Material and methods

Review of the currently available literature and comparison with the author’s experience in tactical medicine.

Results

Guidelines for tactical combat casualty care (TCCC) provide a powerful tool that reduces the risk for responders and casualties and increases the probability of survival by directing the provider towards diagnosis and treatment of the most relevant injury patterns.

Conclusion

The principles of military guidelines are also applicable and successful in civil terrorist scenarios. The key to success is not only the training of medical personnel in these guidelines but also appropriate training and equipment for police forces.

     

Bariatric Surgery Following Total Shoulder Arthroplasty Increases the Risk for Mechanical Complications Including Instability and Prosthetic Loosening

Background

While extensive literature has been published on the risks and benefits of bariatric surgery (BS) prior to and following lower-extremity arthroplasty, no similar investigations have been performed on the impact of BS prior to total shoulder arthroplasty (TSA).

Purpose

The objective of the present study was to compare the incidence of mechanical complications in morbidly obese patients who undergo TSA: those who undergo BS following TSA compared with those who do not undergo BS, and those who undergo BS after TSA compared with those who undergo BS prior to TSA.

Methods

A Medicare database was queried for morbidly obese patients who underwent BS either before or after TSA, as well as those who underwent TSA but no BS. Of 12,277 morbidly obese patients who underwent TSA between 2005 and 2014, 304 underwent BS (165 of them prior to TSA and 139 following TSA) and 11,923 did not undergo BS. Rates of mechanical complications were then compared between groups using a logistic regression analysis.

Results

Patients who underwent BS after TSA had significantly higher rates of mechanical complications (12.9%) compared to controls (8.8%) or patients who underwent prior BS (7.9%). Patients who underwent BS after TSA had higher rates of both instability (7.9%) and loosening (8.6%) than did controls (5.1 and 4.9%, respectively) or patients who underwent BS before TSA (4.8 and 4.2%, respectively).

Conclusions

BS following TSA is associated with increased rates of mechanical complications, including instability and loosening, compared to BS prior to TSA. These findings suggest that it may be prudent to consider performing BS prior to TSA in morbidly obese patients, rather than waiting until after TSA is performed.

     

Tutorial Assistance for Board Certification in Surgery: Frequency,Associated Time and Cost

Background

Tutorial assistance is related to extra time and cost, and the hospitals’ financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance.

Methods

We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time.

Results

On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery.

Conclusions

The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.