Surgical Leadership Training beyond the Traditional Mentorship Model

In this article, I reflect on my experience of being awarded the International Resident Travel Scholarship for “Plastic Surgery the Meeting 2019.” I was the first Indian to be awarded the scholarship, and it offered me not only monetary assistance but also mentorship for future leadership positions. The award further opened doors for several future opportunities in the form of memberships in the American Society of Plastic Surgery (ASPS) committees and Resident Advisory Board of the prestigious “Plastic and Reconstructive Surgery Journal.” I believe this article will make more residents aware and utilize such opportunities for their career development.     

Fellow or foe: the impact of fellowship training programs on the education of Canadian urology residents

Objective

Throughout North America, increasing emphasis is being placed on surgical fellowships. Surgical educators and trainees have raised concerns that the escalating focus on fellowships may threaten the educational mission of more novice trainees. Our objective was to collect opinions from multiple perspectives (faculty, fellows and residents) regarding fellowship structure, fellow selection and the impact of clinical fellowships on urology resident training.

Methods

We anonymously surveyed 52 members of a major academic urology training program (University of Toronto) with established fellowship training programs for their opinions regarding fellowship structure, fellow selection, and the impact on resident training and education.

Results

The overall response rate was 88%. We identified significant differences of opinion among faculty, fellows and residents regarding fellowship structure, fellow selection and the impact on resident education. Specifically, faculty and fellows supported the addition of more fellows, felt that certain complex cases should be designated as “fellow cases” and that residents'' research opportunities were not restricted. Residents felt that fellows “steal” operative cases, that performing operations with the fellow is not equivalent to performing operations with faculty alone and that fellowship candidates should perform an operation with division faculty as part of the application process. There was agreement that fellowship programs add value to residents'' overall education, that fellows should participate in the call schedule and that fellows'' role in the operating room needs to be better defined with respect to case volume and selection. Proficiency in technical skills, clinical knowledge, teaching and teamwork were cited as the most attractive characteristics of an effective clinical fellow.

Conclusion

Residency and fellowship program directors must clearly define the role of the fellow and outline the limits of surgical practice, establish clear and consistent guidelines outlining responsibilities (operative, clinical and on-call), and open lines of communication to ensure that all opinions are recognized and addressed. Finally, they must select fellows with proficient technical skills, clinical knowledge, teaching ability and work ethic to ensure that they focus on “specialized” training.     

Design,Development, and Validation of a High-Fidelity “Ganglion Cyst” Model for Cadaveric Hand Surgery Training

Introduction  This study presents a design and developmental model with prospective validation. This study was aimed to design, develop, and validate a cadaveric model simulator of a ganglion cyst to train surgeons in its surgical excision. Materials and Methods  A novel “ganglion cyst” was designed using a latex powder-free glove and water-based, water-soluble lubricant (K-Y jelly). This “ganglion cyst” was then inserted subcutaneously into a cadaveric hand, positioned over the dorsum of the wrist to simulate a ganglion lesion. This simulation model was prospectively validated using postsimulation surveys conducted on novices and experts in hand surgery. The simulation was conducted during a basic hand surgery cadaveric workshop that included a practical station on ganglion excision. Results  Both the novices and experts had a concurrent agreement that the simulator provided relevance, realism, and value as a simulator for the teaching, excision and procedural assessment of ganglions in the hand. Conclusion  The role of high-fidelity simulation has been documented in the literature for surgical procedures. This simple and affordable model that we have developed and validated allows for the creation of a high-fidelity ganglion simulator in the cadaveric hand for teaching, excision, and procedural assessment among trainees.     

Rationale for participation in venous leg ulcer clinical research: Patient interview study

Recruitment to wound care clinical trials is challenging and a better understanding of patient decisions to participate has the potential to influence recruitment success. We conducted 31 semi‐structured telephone interviews of patients who participated in the Aspirin in Venous Leg Ulcer (ASPiVLU) randomised controlled trail (RCT) or ASPiVLU cohort study. Data were coded and analysed using thematic analysis. We identified four key themes: (a) “I participated to help others”; (b) “I participated in research to thank those who cared for me”; (c) “I participated to receive better care”; and (d) “I participated to have a say on what works.” These themes became basic elements for the Rationale for Research Participation Framework that we have developed to improve the participant recruitment process for clinical trials in wound care.     

Robotic Surgery Training in Gynecologic Fellowship Programs in the United States

Background and Objectives:

The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States.

Methods:

This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary.

Results:

We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21–29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum—95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows.

Conclusion:

Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.     

Theatre ventilation

IntroductionOwing to the COVID-19 pandemic, there has been significant disruption to all surgical specialties. In the UK, units have cancelled elective surgery and a decrease in aerosol generating procedures (AGPs) was favoured. Centres around the world advocate the use of negative pressure environments for AGPs in reducing the spread of infectious airborne particles. We present an overview of operating theatre ventilation systems and the respective evidence with relation to surgical site infection (SSI) and airborne pathogen transmission in light of COVID-19.MethodsA literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Search terms included “COVID-19”, “theatre ventilation”, “laminar”, “turbulent” and “negative pressure”.FindingsEvidence for laminar flow ventilation in reducing the rate of SSI in orthopaedic surgery is widely documented. There is little evidence to support its use in general surgery. Following previous viral outbreaks, some centres have introduced negative pressure ventilation in an attempt to decrease exposure of airborne pathogens to staff and surrounding areas. This has again been suggested during the COVID-19 pandemic. A limited number of studies show some positive results for the use of negative pressure ventilation systems and reduction in spread of pathogens; however, cost, accessibility and duration of conversion remain an unexplored issue. Overall, there is insufficient evidence to advocate large scale conversion at this time. Nevertheless, it may be useful for each centre to have its own negative pressure room available for AGPs and high risk patients.     

Radiologic and Endoscopic Characteristics of Laparoscopic Antireflux Wrap: Correlation With Outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe''s classification of the postoperative valve was used for the definition of a “normal” or “defective” wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A “normal” antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). “Defective” antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.     

Worldwide Trends of Research on Periprosthetic Osteolysis: A Bibliometric Study Based on VOSviewer

BackgroundDue to the increasing number of joint arthroplasty operations, surgeons have begun to devote more attention to the problem of periprosthetic osteolysis. In recent years, numerous studies have focussed on periprosthetic osteolysis, but there have been no relevant bibliometric studies.MethodsWe searched the Web of Science database for relevant articles concerning periprosthetic osteolysis published from 1965 to 2021. The following data were extracted: authors’ name, article title, publication journal, impact factor (IF) of the journal in the publication year, keywords, topic of the article, publication country/region, the sum of times cited, H-index and funding sources. VOSviewer and Excel 2019 were used to conduct the bibliometric study and visualise the analysis.ResultsA total of 1255 publications were included. In all selected articles, “orthopaedics” became the dominant topic (662 of 1255, 52.75%). The most productive years were 2018 and 2019, with a total of 83 publications. The Journal of Arthroplasty published the most articles on periprosthetic osteolysis (110 publications). The United States of America published the most articles (525, 41.83%). The latest keywords “continuous intramedullary infusion”, “erythromycin”, “autophagy”, “bone-resorbing cells” and “proinflammatory cytokines” both appeared in five articles in 2017.ConclusionThis bibliometric study showed that there is a growing trend in published articles related to periprosthetic osteolysis. Journal of Arthroplasty was the top productive journal on periprosthetic osteolysis. The United States of America dominates studies of periprosthetic osteolysis. “Continuous intramedullary infusion”, “erythromycin”, “autophagy”, “bone-resorbing cells” and “proinflammatory cytokines” may be new research hotspots in the field of periprosthetic osteolysis.     

“Motion-specific Headache”: A Predictor for Diagnosis and Favorable Prognosis after Surgery in Young Patients with Chiari Malformation Type 1

As headache is known as one of the most common symptoms in the patients with Chiari malformation type 1 (CM1), it is difficult to find out CM1-related headache among the symptoms because headache itself is commonly seen. Herein, we retrospectively review the cases of six CM1 patients complaining only of headache by which they complained of deterioration in daily life activities. The symptom of headache worsened during anteflexion (n = 2; 33%), retroflexion (n = 1; 17%), jumping (n = 3; 50%), going up the stairs (n = 1; 17%), and running (n = 1; 17%). Mean age at the onset was 15.7 years old (ranging 11–18) and four out of six were female. These inductive factors were clearly different from “Valsalva-like maneuvers,” although the mechanism might originate from dynamic tonsil changes. We named these headaches as “motion-specific.” These headaches radiated to the posterior side. MRI revealed that the extent of tonsillar ectopia was 11.3 mm, while syringomyelia was observed in three out of six patients (50%). All patients underwent surgical treatment, with the “motion-specific headache” completely disappearing 12.5 days thereafter. Although headaches are common, “motion-specific headache” may be a good candidate symptom to distinguish CM1 patients, especially among teenagers with headaches, and a good predictor for favorable outcomes after surgical treatment.     

An Innovative Skin Simulation Model to Augment Competency-based Training in Facial Plastic Surgery

Introduction  Competency-based medical education (CBME) approach in the medical curriculum has been introduced globally with the goal of providing flexibility, accountability, and learner-centeredness among medical learners. Traditional surgical skill training in most places has relied on “see one, do one, teach one model,” while simulation model-based training has been shown to improve competencies in surgical trainees. We wanted to assess the usefulness of a hydrophilic barrier adhesive foam wound dressing as a novel skin simulation model for learning biomechanics and practice of cutaneous flaps among plastic surgical resident trainees at our institute. Materials and Methods  An absorbent, soft polyurethane foam pad located centrally upon a larger polyurethane membrane, coated with a hydrocolloid adhesive, forming an island dressing, was used as a simulation model for this study. It was obtained from the hospital store either after or nearing their expiry dates of clinical use. Plastic surgery residents in different years of training were invited to participate in a simulation workshop, using this novel model, and give their feedback. Results  Seventeen residents in different plastic surgery training levels participated in the workshop and gave their feedback on the skin flap simulation model. The simulation model received extremely high (100%) scores on two parameters, namely, utility for flap and suture practice and high scores (88%–94%) for texture, ability to mark, and improving confidence among trainees. Conclusions  Adhesive bilayer polyurethane foam can be used as a novel cutaneous skin flap simulation model for understanding the biomechanics of skin flaps and cutaneous flap practice.     

Cost Analysis of Establishing a Relationship Between a Surgical Program in the US and Vietnam

“Twinning” refers to a constructive partnership between hospitals in developed and developing nations. Such an effort may contribute immensely to capacity building for the developing nation, but one of the reasons given for the lack of sustainability is cost. We share a detailed operating cost analysis of our recent experience with an institution in Vietnam. We were awarded a 1-year $54,000 grant from the Vietnam Education Foundation (VEF) to conduct a live tele-video conferencing course on the “Fundamentals of Clinical Surgery” with Thai Binh Medical University (TBMU). In-country lectures as well as an assessment of the needs at TBMU were performed. Total financial assistance and expenditures were tabulated to assess up-front infrastructure investment and annual cost required to sustain the program. The total amount of direct money ($66,686) and in-kind services ($70,276) was $136,962. The initial infrastructure cost was $41,085, which represented 62% of the direct money received. The annual cost to sustain the program was approximately $11,948. We concluded that the annual cost to maintain a “twinning” program was relatively low, and the efforts to sustain a “twinning” program were financially feasible and worthwhile endeavors. “Twinning” should be a critical part of the surgical humanitarian volunteerism effort.     

Urology at your fingertips: the development of a urology m-learning app for medical students

BackgroundSurgical education has embraced advancing technology with an emphasis on e-learning in recent years. Smartphones are a useful tool for medical teaching and learning with increasing use by medical students to access e-books, medical calculators, podcasts, and medical applications (apps). Our aim was to develop a dedicated urology app for medical students as an adjunct to traditional teaching.MethodsWe published an e-book: Urology Handbook for Medical Students in 2017 based on the core urology curriculum for medical students. Subsequently, we developed a concise, simple and user-friendly smartphone app for medical students called “Urology Med”, available for download on App Store and Google Play.ResultsThis app is an introduction to urology for medical students but may also be useful for interns and surgical trainees. The app encompasses core urology topics subdivided into common urological presentations, urological examination, urological diseases, and urological devices. To make the app interactive, it includes 5 clinical cases that complement the reading material and six quizzes for self-assessment. A comprehensive checklist of 31 “must see” and “good to see” urology experiences is included. Within one month of launch, the app was downloaded 435 times in five countries across three continents. It has a 5-star rating on the Apple store.ConclusionsHigh educational standards with relevant content make e-learning a valuable learning tool for surgical education. The Urology Med app facilitates easy access to urology and is ideal for quick reading while working or revising.     

Nasal Methicillin-Resistant S. Aureus is a Major Risk for Mediastinitis in Pediatric Cardiac Surgery

Background: Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication after pediatric cardiac surgery. An outbreak of surgical site infections (SSIs) provided the motivation to implement SSI prevention measures in our institution.Methods: Subjects comprised 174 pediatric patients who underwent open-heart surgery after undergoing preoperative nasal culture screening. The incidence of SSIs and mediastinitis was compared between an early group, who underwent surgery before SSI measures (Group E, n = 73), and a recent group, who underwent surgery after these measures (Group R, n = 101), and factors contributing to the occurrence of mediastinitis were investigated.Results: The incidence of both SSIs and Mediastinitis has significantly decreased after SSI measures. With regard to factors that significantly affected mediastinitis, preoperative factors were “duration of preoperative hospitalization” and “preoperative MRSA colonization,” intraoperative factors were “Aristotle basic complexity score,” “operation time,” “cardiopulmonary bypass circuit volume” and “lowest rectal temperature.” And postoperative factor was “blood transfusion volume.” Patients whose preoperative nasal cultures were MRSA-positive suggested higher risk of MRSA mediastinitis.Conclusions: SSI prevention measures significantly reduced the occurrence of SSIs and mediastinitis. Preoperative MRSA colonization should be a serious risk factor for mediastinitis following pediatric cardiac surgeries.     

A retrospective review of general surgery training outcomes at the University of Toronto

Background

Surgical educators have struggled with achieving an optimal balance between the service workload and education of surgical residents. In Ontario, a variety of factors during the past 12 years have had the net impact of reducing the clinical training experience of general surgery residents. We questioned what impact the reductions in trainee workload have had on general surgery graduates at the University of Toronto.

Methods

We evaluated graduates from the University of Toronto general surgery training program from 1995 to 2006. We compared final-year In-Training Evaluation Reports (ITERs) of trainees during this interval. For purposes of comparison, we subdivided residents into 4 groups according to year of graduation (1995–1997, 1998–2000, 2001–2003 and 2004–2006). We evaluated postgraduate “performance” by categorizing residents into 1 of 4 groups: first, residents who entered directly into general surgery practice after graduation; second, residents who entered into a certification subspecialty program of the Royal College of Physicians and Surgeons of Canada (RCPSC); third, residents who entered into a noncertification program of the RCPSC; and fourth, residents who entered into a variety of nonregulated “clinical fellowships.”

Results

We assessed and evaluated 118 of 134 surgical trainees (88%) in this study. We included in the study graduates for whom completed ITER records were available and postgraduate training records were known and validated. The mean scores for each of the 5 evaluated residency training parameters included in the ITER (technical skills, professional attitudes, application of knowledge, teaching performance and overall performance) were not statistically different for each of the 4 graduating groups from 1995 to 2006. However, we determined that there were statistically fewer general surgery graduates (p < 0.05) who entered directly into general surgery practice in the 2004–2006 group compared with the 1998–2000 and 2001–2003 groups. The graduates from 2004 to 2006 who did not enter into general surgery practice appeared to choose a clinical fellowship.

Conclusion

These observations may indicate that recent surgical graduates possess an acceptable skill set but may lack the clinical confidence and experience to enter directly into general surgery practice. Evidence seems to indicate that the clinical fellowship has become an unregulated surrogate extension of the training program whereby surgeons can gain additional clinical experience and surgical expertise.     

The Learning Curve of Laparoendoscopic Single-Site (LESS) Fundoplication: Definable,Short, and Safe

Background and Objectives:

This study of laparoendoscopic single-site (LESS) fundoplication for gastroesophageal reflux disease was undertaken to determine the “learning curve” for implementing LESS fundoplication.

Methods:

One hundred patients, 38% men, with a median age of 61 years and median body mass index of 26 kg/m², underwent LESS fundoplications. The operative times, placement of additional trocars, conversions to “open” operations, and complications were compared among patient quartiles to establish a learning curve. Median data are reported.

Results:

The median operative times and complications did not differ among 25-patient cohorts. Additional trocars were placed in 27% of patients, 67% of whom were in the first 25-patient cohort. Patients undergoing LESS fundoplication had a dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P < .05), particularly for heartburn and regurgitation, without causing dysphagia.

Conclusion:

LESS fundoplication ameliorates symptoms of gastroesophageal reflux disease without apparent scarring. Notably, few operations required additional trocars after the first 25-patient cohort. Patient selection became more inclusive (eg, more “redo” fundoplications) with increasing experience, whereas operative times and complications remained relatively unchanged. The learning curve of LESS fundoplication is definable, short, and safe. We believe that patients will seek LESS fundoplication because of the efficacy and superior cosmetic outcomes; surgeons will need to meet this demand.     

Immediate and Delayed Complications Following Endoscopic Skull Base Surgery

Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery. Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as “perioperative” (within 1 week), “early” (after 1 week and within 6 months), or “delayed” (after 6 months). Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively). Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.