Teaching Microsurgical Breast Reconstruction—A Retrospective Cohort Study

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, ”no-training group”), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery (“passive training”); by the trainee, and a senior surgeon was supervising (“active training”); or by the trainee without a senior surgeon (“after training”). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

The role of AIHIP in Preoperative Planning of Total Hip Arthroplasty to Different Surgeons.

BackgroundPreoperative planning with computed tomography (CT)-based three-dimensional templating has been achieved more precise placement of hip components. This study investigated the value of the software for preoperative planning (artificial intelligence hip system, AIHIP) in primary total hip arthroplasty (THA) for surgeons with different experience levels.MethodsWe performed a retrospective study of 240 hips in 240 patients who underwent cementless primary THA. The patients were divided into four groups: A1) senior surgeon without AIHIP, A2) senior surgeon with AIHIP, B1) junior surgeon without AIHIP, and B2) junior surgeon with AIHIP. All preoperative planning evaluations were completed using the AIHIP software. We analysed the accuracy of stem size prediction and cup size prediction, the absolute value of postoperative discrepancy in leg length, discrepancy of neck-shaft angle and femoral offset between the healthy side and the affected side from the anteroposterior radiographic view of the hip, intraoperative and postoperative complications, operative times, the reduction in the haemoglobin (Hb) level during the first 24 hours and the number of intraoperative radiations.ResultsThe sizes of 95% were accurately estimated to be within one stem size, and 97% of the cup size estimates were accurate to within one cup size in group A2. A total of 87% were accurately estimated to be within one stem size, and 85% were accurate to within one cup size in group B2. There was a significant difference in radiological indicators (P<0.050), postoperative complications (overall P=0.035), operation duration (P<0.001), decrease in Hb per 24 hours (P=0.046) and intraoperative radiation frequency (P<0.050) among the patients in group B. There was also a significant difference in postoperative complications (overall P=0.01) between groups A1 and B1.ConclusionOur results suggest that the AIHIP is a favourable tool for young surgeons, and the accuracy is good.

SP2.2.6An audit on core surgical trainees’ operating theatre experience to improve compliance against JCST training quality indicators

Aims The primary aim of this study was to audit the experience of core surgical trainees in operating theatres with a view to devise some interventions to improve the quality of theatre experience. Methods This study was a prospective audit that involved filling out a set proforma by all core surgical trainees working in a busy surgical department of a tertiary care university hospital. The proforma included a breakdown of questions to signpost indicators of quality experience and check compliance with the Joint Committee on Surgical Training (JCST) guidelines. It was completed with particular consideration given to the experience while trainees were on their CEPOD week to facilitate accuracy and relevance of feedback. Results 8 core surgical trainees filled out the proforma. 75% of trainees had the opportunity to reflect the case with the senior surgeon. Lowest compliance was shown for pre-operative discussion of crucial learning points with the senior surgeon. Only 50% of trainees had a chance to do a briefing pre-operatively which is one of the JCST quality indicator for core surgical trainees. Conclusion This audit demonstrates the potential for improvement in the operating theatre experience of junior surgical trainees considering JCST Quality Improvement indicators. A checklist may be introduced to achieve maximum utilisation of the finite training opportunities available to current junior surgical trainees. A loop closing audit after the checklist will be able to assess the change in practice and theatre experience.

Percutaneous Endoscopic Interlaminar Discectomy for L5-S1 Axillary-Type Disc Herniation, with Surgeon Stand on an Opposite Side of Disc Protrusion to Perform

Background: It is widely acceptable that surgeon stand on the same side of the disc protrusion to perform PEID. Few study focus on PEID being performed when surgeon stand on the opposite side of the disc protrusion. The aim is to investigate the feasibility and efficacy of an different approach that surgeon stood on the opposite side of the disc protrusion to perform PEID. Methods: A total of 40 patients with radiculopathy due to L5-S1 disc herniation underwent PEID were included in this study. All surgeries were performed by a senior surgeon who stood on the opposite side of the disc protrusion. The pre- and postoperative VAS, JOA, ODI and modified MacNab scores, as well as postoperative complications were collected.Results: All patients were followed up and the average follow-up period was 12.7 months. The VAS, JOA and ODI score were significantly improved after surgery. The excellent and good rate was 90% of the patients according to MacNab criteria. Recurrence without reoperation was observed at 6 months in 2 patient. No patient had major complications at the last follow-up except three cases who complained of transient lower limbs numbness. Conclusion: In this study, we found axillary herniated discs could be removed easily when surgeon stood on the opposite side of the disc protrusion. A working cannula was introduced into the epidural space at an less steeper angle to the skin, which can effectively reduce the risk of dura sac injury.

Can Tonsillectomy Be Safely Performed by Residents? A Comparative Retrospective Study

Objective: To assess whether a surgeon’s level of training is associated with outcomes in pediatric tonsillectomy. Design: A retrospective cohort study of the outcomes of pediatric tonsillectomies performed between 2006 and 2016 by senior surgeons versus resident surgeons under the supervision of senior surgeons. Setting: An otolaryngology department in a tertiary academic hospital. Patients: Children younger than 18 years who underwent bilateral tonsillectomy with or without adenoidectomy. Main outcome measures: Intraoperative bleeding, initiation of oral intake, and intraoperative and postoperative complications. Results: Of 785 children, 397 (50.5%) were operated on by a resident surgeon and 388 (49.5%) by a senior surgeon. Patient demographics and surgical techniques were similar between the groups. The mean surgical time was 33.2 minutes in the residents’ group and 27.1 minutes in the seniors’ group ( P = .032). The groups were similar in intraoperative bleeding, while same-day initiation of oral intake was 71% for children in the residents’ group versus 61% in the seniors’ group ( P = .28). Reports of postoperative bleeding necessitating readmission and revised operations were similar for both groups (3.0% and 0.7%, respectively, in the residents’ group; and 2.5% and 1.0%, respectively, in the seniors’ group). Conclusion: Children undergoing tonsillectomy showed similar short-term outcomes, whether the operations were performed by a senior surgeon or a resident surgeon supervised by an attending surgeon. This study demonstrates the safety of pediatric tonsillectomy performed by resident surgeons supervised by attending physicians.

Surgery to relieve nasal obstruction: outcome for 366 patients operated on by one senior surgeon

Background Studies of patient-rated outcome in septoplasty and turbinoplasty most frequently involve several surgeons with varying surgical skills, techniques and experience. The aim of the present study was to evaluate outcome based on one experienced surgeon. Methods Three hundred and sixty-six consecutive patients referred for nasal obstruction were included. All the patients were examined with nasal endoscopy before and after decongestion, they filled out a nose VAS and rated their overall general health before and three to six months after surgery. The patients underwent septoplasty, septoplasty plus turbinoplasty or turbinoplasty. Results The mean nose VAS for nasal obstruction (0–100) preoperatively was 64.7 for all patients. Patients undergoing septoplasty (n = 159) were younger than patients undergoing septoplasty + turbinoplasty (n = 79) or patients undergoing turbinoplasty alone (n = 128). The nose VAS for nasal obstruction improved significantly in all three groups and 25% had a normal nose VAS after surgery in the septoplasty and septoplasty + turbinoplasty groups compared to only 8% in the turbinoplasty alone group. There was no significant difference in the improvement in nasal obstruction between septoplasty and septoplasty + turbinoplasty, but the septoplasty + turbinoplasty group experienced a significantly greater improvement in general health. Conclusions In 366 patients operated on by one experienced surgeon, septoplasty and septoplasty + turbinoplasty were more effective at relieving nasal obstruction than turbinoplasty alone. Septoplasty + turbinoplasty resulted in a greater improvement in general health than septoplasty alone, despite the same improvement in nasal obstruction, indicating a beneficial effect of additional turbinoplasty in septoplasty.

In-Practice Endocrine Surgery Fellowship: A Novel Training Model

Objective Endocrine surgery is an expanding field within otolaryngology. We hypothesized that a novel endocrine surgery fellowship model for in-practice otolaryngologists could result in expert-level training. Study Design Qualitative clinical study with chart review. Setting Urban community practice and academic medical center. Methods Two board-certified general otolaryngologists collaborated with a senior endocrine surgeon to increase their endocrine surgery expertise between March 2015 and December 2017. The senior surgeon provided intensive surgical training to both surgeons for all of their endocrine surgeries. Both parties collaborated with endocrinology to coordinate medical care and receive referrals. All patients undergoing endocrine surgery during this time frame were reviewed retrospectively. Results A total of 235 endocrine surgeries were performed. Of these, 198 thyroid surgeries were performed, including 98 total thyroidectomies (48%), 90 lobectomies (45%), and 10 completion thyroidectomies (5%). Sixty cases demonstrated papillary thyroid carcinoma, 11 follicular thyroid carcinoma, and 4 medullary thyroid carcinoma. Neck dissections were performed in 14 of the cases. Thirty-seven parathyroid explorations were performed. There were no reports of permanent hypoparathyroidism. Thirteen patients (5.5%) developed temporary hypoparathyroidism. Six patients (2.5%) developed postoperative seroma. Three patients (1.3%) developed postoperative hematomas requiring reoperation. One patient (0.4%) developed permanent vocal fold paralysis, and 3 patients (1.3%) had temporary dysphonia. Thirty-five of 37 (94.5%) parathyroid explorations resulted in biochemical resolution of the patient’s primary hyperparathyroidism. Conclusion This is the first description of a new fellowship paradigm where a senior surgeon provides fellowship training to attending surgeons already in practice.

Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon. Methods All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures. Results The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively. Conclusion Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK

ObjectiveThis study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery.MethodsA retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties.ResultsIn total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent.ConclusionThis study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.