Full-endoscopic spine surgery diminishes surgical site infections – a propensity score-matched analysis

BACKGROUND CONTEXTSurgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.PURPOSEThe purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.DESIGNThis is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.PATIENT SAMPLEA total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.OUTCOME MEASURESThe occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.METHODSAll FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.RESULTSIn the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009–0.461, p=.006) favoring FESS.CONCLUSIONSFESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.     

Congenital heart defects – occurrence,surgery and prognosis in a Danish County

Objectives—To present population‐based data on prevalence, surgery and mortality for infants and children up to 5 years of age with congenital heart disease (CHD).

Design—Data from the EUROCAT Registry of Congenital Malformations for Funen County, Denmark, 1986–1998.

Results—Five hundred and seventy‐three infants and children were diagnosed with a CHD and livebirth prevalence was 7.9 per 1000 births. Thirty‐two per cent of all infants and children had an intervention (surgery or catheter treatment) performed. Eighteen per cent died within the first 5 years with the majority of deaths within the first year of life. For 74% of all deaths, surgery had not been performed. There was a decline in mortality for 1994–1998 compared to 1986–1993 both as a percentage of all cases (p?<?0.05) and as deaths per 1000 births (p?=?0.13), and deaths within the first 28?d after surgery almost disappeared during the study period.

Conclusion—Mortality and morbidity for infants and children with CHD is rather high although surgical mortality has improved considerably. Survival may be improved further for the small group of severely ill newborns dying before surgery. In newborns with multiple malformations, however, survival might not be possible or desirable.     

Is there still a role for experimental surgery in the surgical sciences?

The firm opposition of public opinion and the reduction in public funding have remarkably curtailed the role of experimental surgery which several years ago was a key aspect of the activity of a surgical department. Experimental surgery in large animals has been virtually banned and experimental research in small animals requires the use of complex microsurgical techniques. In our opinion, experimental surgery is still useful in order to test new surgical devices and new drugs, especially in the field of transplant surgery. Another important function of experimental surgery is to facilitate the training of surgical residents in order to speed up the process of acquiring experience and expertise. Public opinion can be reassured because the legislation is very strict and safeguards the well-being of animals.     

Pediatric surgical capacity building – a pathway to improving access to pediatric surgical care in Haiti

Purpose

Lack of human resources is a major barrier to accessing pediatric surgical care globally. Our aim was to establish a model for pediatric surgical training of general surgery residents in a resource constrained region.

3D ultrasound navigation in syrinx surgery – a feasibility study

Summary Background. The prototype of a 3D ultrasound navigation system, with a trackable 4- to 8-MHz phased-array ultrasound probe was used in syrinx-surgery. The aim of this study was to evaluate the advantages offered by 3D ultrasound and navigation in syringomyelial surgery.Methods and materials. After laminectomy, with a free-handed tilt of the ultrasound probe, the 3D volume of the target area is acquired within 15 seconds. The data are visualized after reconstruction in an axial, coronal, and sagittal view, offering the possibility of ultrasound-based guided surgery.Results. Based on the intraoperative volume information, it was possible to navigate with the 3D ultrasound images in all cases. The orientation and image quality with respect to resolution, spatial information, and the identification of anatomical structures facilitated the surgery in all seven cases.The navigation tool, with a length of 12cm and a tip diameter of 1mm, was simple to place into the surgical site. The availability of an up-to-date 3D-image resulted in less interruption of the surgical procedure, with no need to repeatedly fill the cavity with sterile saline for new ultrasound acquisitions. New ultrasound images were only required if shift occurred.The coronal and trajectory-plane views, offer additional information about the syrinx cavity. The target borders are easier to determine and orientation in separated cavities was possible. Particularly in syringomyelial surgery it was helpful to determine the surface point of the syrinx to place the myelotomy or insert a catheter.Conclusion. 3D ultrasound offers the advantages of visualizing the third dimension of the target. For orientation and border determination navigation within the 3D ultrasound volume is very helpful and can take place with the ultrasound probe out of the way. Any disruption in the surgical procedure is minimized by not having to repeatedly fill the cavity with a sterile saline solution, there are fewer difficulties with image orientation because of new image adjustments.     

A core undergraduate curriculum in plastic surgery – a Delphi consensus study in Scandinavia

Background and aims: In recent years, undergraduate medical education has undergone a transition from a speciality-based to a more competence-based training system. Consequently, whilst medical knowledge is rapidly expanding, time for teaching of the surgical specialties is decreasing. Thus, there appears to be a need to define the core competences that are to be taught. The aim of this study was to establish a Scandinavian core undergraduate curriculum of competences in plastic surgery, using scientific methods.

Methods: The Delphi technique for group consensus was employed. An expert panel was recruited from various plastic surgery subspecialties, institutions, and levels of clinical experience, in four Nordic countries (Denmark, Finland, Norway and Sweden). Questionnaires were sent out and answers collected electronically via Google Forms?. Following completion of three predefined rounds of anonymous questionnaires; a final core curriculum competency list was agreed upon based on a consensus agreement level of 80%.

Results: Two hundred and ninety-five competences were suggested in the first round. In the second round, 76 competences (33 skills and 43 knowledge items) received a score ≥3.00 on a 1–4 Likert scale. Final agreement in the third round resulted in a list of 68 competences with agreement above 80% (31 skills and 37 knowledge items).

Conclusions: This study proposes the first scientifically developed undergraduate core curriculum in plastic surgery. It comprises of a consensus of competences a recently graduated medical doctor should be expected to possess.     

Tracheal tube size in adults undergoing elective surgery – a narrative review

Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with 7–7.5 mm and 8–8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6–6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim-line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator-induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri-operative management.     

Is the skillset obtained in surgical simulation transferable to the operating theatre?

BackgroundSimulated surgical training offers a safe and accessible way of learning surgical procedures outside the operating room. Training programs have been developed using simulated laboratories to train surgical trainees to proficiency outside the operating room. Despite the global enthusiasm among educators to enhance training through simulation-based learning, it remains to be elucidated whether the skill set obtained is transferrable to the operating room.MethodsUsing standardized search methods, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web-Based Knowledge, as well as the reference lists of relevant articles, and retrieved all published randomized controlled trials.ResultsSixteen randomized controlled trials involving 309 participants were identified to be suitable for qualitative analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The mean Consolidated Standards of Reporting Trials score was 16 (range, 12–22). The studies showed considerable clinical and methodologic diversity. Operative time improved consistently in all trials after training and was the only objective parameter measurable in the live setting. Studies that used the Objective Structured Assessment of Technical Skills as their primary outcome showed improved scores in 80% of trials, and studies that used performance indicators to assess participants all showed improved scores after simulation training in all of the trials, with 88% showing statistical significance.ConclusionsThe current literature consistently demonstrates the positive impact of simulation on operative time and predefined performance scores. However, these reproducible measures alone are insufficient to demonstrate transferability of skills from the laboratory to the operating room. The authors advocate a multimodal assessment, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion. This may provide a more complete assessment of operative performance. Only then can it be concluded that simulation skills are transferable to the live operative setting.     

Developing a surgical practice – It's a lot of hard work

A successful surgical practice, and there are many definitions of that based on personal desires and goals, requires a tremendous amount of effort to establish and maintain. The successful surgeon, however, has usually mastered three main areas. They have chosen a practice that maximizes their strengths, they have mastered the “Three A's” affability, availability and clinical ability and they have balanced work and life. All of these factors take daily effort and will result in the practice that you desire.     

Laparoscopic orchiectomy for the adult impalpable testis – experiences in a rural teaching hospital

Background Undescended testis is a relatively common condition in boys. The standard treatment is orchiopexy. In adults, orchiopexy is done only if sufficient length can be mobilized. Otherwise, orchiectomy is ideal as undescended testis predisposes to carcinoma. The incidence of carcinoma increases with age. The aim of this study is to highlight the value of laparoscopy in treatment of impalpable testis and simultaneously repair associated hernias. This is our experience in a rural tertiary hospital. Methods In our rural hospital, it is not uncommon to see men aged 30 years or more presenting with unilateral absence of testis/empty hemiscrotum. A total of 35 patients were studied. Ultrasonography of the abdomen was done to localize the exact position of the testis; it was detected in 12 cases. A computed tomography (CT) scan was done in the other 23 cases and was positive in 16. The testis was found in the retroperitoneum (close to the internal inguinal ring) in 12 cases and in the inguinal canal in 23 cases. There were associated hernias in 9 patients. Results Laparoscopy accurately identified the exact location of the missing testis and resection was also accomplished and associated hernias were repaired laparoscopically. Discussion In countries like India, the majority of the population is poor and illiterate. By the time a boy or young man with an undescended testis arrives at the hospital, it is already too late to do orchiopexy. Even though most of our patients had no symptoms, orchiectomy had to be done because of the risk of torsion and malignant transformation. By using laparoscopy in these patients, the advantages of minimally invasive surgery can be utilized. Conclusions Laparoscopic orchiectomy seems to be advantageous and well received by patients. We preferred the laparoscopic approach for the obvious benefits of less pain, better cosmesis, and early discharge.     

Jan Hendrik Louw and intestinal atresia – a personal quest in pediatric surgery

Jan Hendrik Louw (1915–1992), considered the father of pediatric surgery in South Africa, gained prominence for his work on congenital intestinal atresia, a condition that had a mortality as high as 75 percent. His hypothesis, that jejunoileal atresia arose from mesenteric circulatory accidents in utero, was the dominant view until recent research uncovered the involvement of genetic and embryological mechanisms. In the mid-1950s he was one of a number of surgeons to resect the enlarged bulbous segment proximal to the site of the atresia, a crucial step in the surgical approach to intestinal atresia that brought mortality below 10 percent. A world leader in surgery as chair of surgery at the Groote Schur Hospital in Cape Town for more than a quarter century, his work in surgical research took root from his private tragedy early in his career of the death of his own infant son of intestinal atresia, a condition to which he would contribute so much.     

Is actual surgical experience reflected in virtual reality simulation surgery for a femoral neck fracture?

Introduction

A virtual reality simulator developed for orthopaedic and trauma surgical training has been introduced. However, it is unclear whether the experiences of actual surgery are reflected in virtual reality simulation surgery (VRSS) using a simulator. The aim of this study is to investigate whether the results in VRSS differ between a trauma expert and a trauma novice.

Methods

In Group A (expert), there are ten orthopaedic trauma surgeons and in Group B (novice) ten residents within 2 years after medical school graduation. VRSS for a femoral neck fracture using Hansson hook-pins (Test 1) and Hansson twin hook plate (Test 2) was performed. The parameters evaluated were total procedure time (s), fluoroscopy time (s), number of times X-ray was used (defined by the number of times the foot pedal was used), number of retries in guide placement, and final implant position.

Results

In Test 1, the averages of four parameters (distance to posterior cortex (p = 0.009), distal pin distance above lesser trochanter (p = 0.015), distal pin hook angular error (p = 0.004), and distal pin tip distance to centre (lateral) (p = 0.015)) were significantly different between Groups A and B. In Test 2, no parameters in a mean were significantly different between groups, but seven parameters in a variance (guide wire distance to joint surface (p = 0.0191), twin hook length outside barrel (p = 0.011), twin hook tip distance to centre (lateral) (p = 0.042), twin hook distance to centre of lateral cortex (lateral) (p = 0.016), plate end alignment error (lateral) (p = 0.027), guide wire angle with lateral cortex (front) (p = 0.024), and 3.2-mm drill outside cortex (p = 0.000)) were significantly different between groups. In Test 1, Group B showed significantly longer fluoroscopy time than Group A (p = 0.044). In Test 2, Group B showed significantly fewer instances of X-ray use than Group A (p = 0.046).

Conclusions

Our study showed that the experiences of actual surgery are reflected in the result of VRSS using the simulator.

     

Can skills assessment on a virtual reality trainer predict a surgical trainee’s talent in laparoscopic surgery?

Background A number of studies have investigated several aspects of feasibility and validity of performance assessments with virtual reality surgical simulators. However, the validity of performance assessments is limited by the reliability of such measurements, and some issues of reliability still need to be addressed. This study aimed to evaluate the hypothesis that test subjects show logarithmic performance curves on repetitive trials for a component task of laparoscopic cholecystectomy on a virtual reality simulator, and that interindividual differences in performance after considerable training are significant. According to kinesiologic theory, logarithmic performance curves are expected and an individual’s learning capacity for a specific task can be extrapolated, allowing quantification of a person’s innate ability to develop task-specific skills. Methods In this study, 20 medical students at the University of Basel Medical School performed five trials of a standardized task on the LS 500 virtual reality simulator for laparoscopic surgery. Task completion time, number of errors, economy of instrument movements, and maximum speed of instrument movements were measured. Results The hypothesis was confirmed by the fact that the performance curves for some of the simulator measurements were very close to logarithmic curves, and there were significant interindividual differences in performance at the end of the repetitive trials. Conclusions Assessment of perceptual motor skills and the innate ability of an individual with no prior experience in laparoscopic surgery to develop such skills using the LS 500 VR surgical simulator is feasible and reliable.     

Single-incision laparoscopic surgery (SILS?) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator

Background  

Single-incision laparoscopic surgery (SILS™) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS™ may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS™ technique.