Is unplanned return to the operating room a useful quality indicator in general surgery?

HYPOTHESIS: To test our hypothesis that unplanned return to the operating room (OR) is a useful quality indicator, we examined how often and for what reasons patients go back to the OR in a broad-based general surgery practice. DESIGN AND SETTING: Prospective cohort study at a rural tertiary care center. PATIENTS: Consecutive series of 3044 patients undergoing general surgery procedures in the OR between September 1, 1998, and March 31, 2000. Information about all postoperative adverse events occurring before discharge or within 30 days (whichever was longer) was collected prospectively. Unplanned return to the OR was defined as any secondary procedure required for a complication resulting directly or indirectly from the index operation. MAIN OUTCOME MEASURES: Unplanned return to the OR, mortality, and hospital charges. RESULTS: Overall, 107 (3.5%) had an unplanned return to the OR. A relatively small number of inpatient procedures accounted for a disproportionate share of unplanned reoperations, including colon resection (18% of total reoperations), renal transplant (9%), gastric bypass (6%), and pancreatic resection (6%). As expected, hospital charges were markedly higher for patients with unplanned returns to the OR. Reoperation was also associated with higher mortality rates; statistically significant increases were noted for pancreatic resection (33% vs 3.7%; P =.04), esophagogastrectomy (100% vs 4.2%; P =.002), and laparoscopic Nissen fundoplication (50% vs 0%; P =.01). Overall, 91 reoperations (85%) were for complications occurring at the original surgical site, including those related to an anastomosis (n = 16), surgical wound (n = 21), infection (n = 16), bleeding (n = 12), and other (n = 26). CONCLUSIONS: Unplanned returns to the OR occur across a broad spectrum of general surgical procedures and carry significant implications. Because they most often reflect problems related to the procedure itself, reoperation rates may be useful for monitoring quality across hospitals and for identifying opportunities for quality improvement locally.     

Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?

Background

Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.

Methods

Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ² analysis.

Results

The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (n = 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (p < 0.0001). One surgeon (1.3 %) failed the skills certification, and nine (11.8 %) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34 % compliance). All achieved proficiency at skills, and 60 % passed the cognitive exam.

Conclusions

This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33 % and a certification failure rate of 13 % suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.     

Peripheral nerve surgery

周围神经损伤以后的功能恢复，仍然是21世纪的主要目标。脊髓水平的神经修复是一个新而具有挑战性的技术，对神经元再生的深入理解（包括神经元误向生长与存活问题）与实验手段的完善（包括基因调控的成纤维细胞和雪旺细胞种植等），将使臂丛外科（学）进入一个新的水平。鉴于运动轴突对肌皮瓣再神经化的意义，区分感觉和运动神经束的选择性神经缝合，在游离神经血管肌肉移植术中取得了较好的效果。用纤维蛋白胶或激光缝合的无缝线缝合技术，因两端神经连接不牢，故只能是一种辅助的神经修复手段。应用邻近正常神经行部分端端或端侧缝合，对解决供体神经的来源和保存供体神经功能来说，是一个有前途的方法。然而，正常的供体神经切除后的代偿机制及神经端侧缝合效果，尚需进一步研究。神经移植术的结果仍不令人满意。在长段神经缺损，神经主干移植及组织床为瘢痕或骨质时，可考虑用带血管的自体神经移植术。预变性神经或预处理神经移植术，能调控雪旺细胞和成纤维细胞，从而影响神经再生，但对离体/在体及预变性时间方面，仍存在着争议。随着细胞培养学和组织工程学技术的广泛应用，人工生物神经移植物将代替自体神经移植物。顾玉东院士首创“寄养法”预防手内部肌萎缩，也可应用感觉神经和背根神经节预防肌肉萎缩。总之，随着对神经再生的神经生物学和分子水平进一步的深入研究，周围神经外科学将会取得更大的进展。     

Varicocoele surgery as day surgery—a regional hospital experience

From July 1994 to February 2001, 60 patients underwent varicocoele surgery in the Day Surgery Centre, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, PRC. The mean age of these patients was 25.9 years (ranged 9–66). Their symptoms included pain/discomfort (41.7%), mass/swelling (36.7%), infertility (8.3%) and cosmetic reasons (1.7%). In seven patients the indication was not clearly defined. 31 (51.7%) varicocoele operations were laparoscopically performed, 26 (43.3%) by an open method and in four patients (6.7%) the method was not mentioned. The median operative time was 34 min. We successfully reduced or abolished the symptoms of varicocoele in 68.7% of patients whose indication was pain or discomfort and restored fertility in 80% of patients whose indication was infertility. There was only one unplanned hospital admission. There were no anaesthetic or post-operative complications. Varicocoele surgery performed on a day surgery basis is feasible, with a high operative success rate and potential cost reduction.