Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study

Background. The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied. Methods. The Current Procedural Terminology (CPT) codes comprising the “core” procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training. Results. In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication ( p = 0.006 ) and greater need for transfusion ( p = 0.001 ) but also tended to be used in cases of longer duration ( p = 0.001 ) and with higher total work relative value units (wRVUs) ( p = 0.001 ). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p = 0.002 ), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p = 0.010 ) and lower extremity location of the tumor (OR 4.393, p = 0.006 ). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis. Conclusions. Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.

What do cardiac surgical assistants in the Kingdom of Saudi Arabia think about their job? A cross-sectional survey of job and work characteristics

Concerns about job design of the cardiac surgical assistant workforce such as role autonomy and job dissatisfaction have been outlined in the literature, although scant empirical research has examined these concerns from the perspective of cardiac surgical assistants themselves. This study surveyed the job design of cardiac surgical assistants in the Kingdom of Saudi Arabia using Morgeson and Humphrey’s Work Design Questionnaire. All scalable items within the questionnaire were reported as satisfactory except for ‘autonomy’, ‘task identity’, ‘feedback from the job’, ‘job complexity’, ‘social support’, ‘feedback from others’, ‘ergonomic’ and ‘work condition’. The results provide insight into aspects of cardiac surgical assistants’ role characteristics and contribute to the body of knowledge about their organisational psychology. Given the growth of cardiothoracic operations, the role of the surgical care assistant needs to be further developed to address the job design issues raised.

Barriers to Reporting Clinical Errors in Operating Theatres and Intensive Care Units of a Teaching Hospital: A Phenomenological Study

Background: Clinical errors are one of the challenges of health care in countries; moreover, the obtaining of accurate statistics regarding clinical errors in most countries is a difficult process and varies from one study to another. The current study was conducted to identify impediments in the reporting of clinical errors in the operating theatre and the intensive care unit of a teaching hospital.Methods This study was conducted qualitatively in the operating theatre and intensive care sections of a training hospital. Data collection was conducted through semi-structured with medical care staff and senior doctors and surgical assistants. Data analysis was carried out through listening to recorded interviews and developing tape scripts of the interviews. The meaning units were identified and codified based on the type of discussion. Furthermore, codes which had a common concept were categorized in one group and by using the designated groups, the main problems were derived. Finally, the codes and designated groups were analyzed, discussed and confirmed by a panel of four experts in qualitative content, and the existing main problems were identified and categorized.Results: Barriers to reporting clinical errors were extracted in two themes: individual and organizational problems. Individual problems included 4 categories and 12 codes and organizational problems included 6 categories and 17 codes. The results showed that in the majority of cases, nurses indicated their desire to change current prevailing attitudes in the workplace while doctors expected reform policies dealing with clinical errors in teaching hospitals to be implemented at higher levels by officials. Conclusion: in order to alleviate Barriers to reporting clinical errors, individual problems and organizational problems should be resolved. To reduce individual problems, it is recommended to train the nursing and medical team in the field of error recognition. In order to solve organizational problems in the nursing team, improve the process of reporting clinical errors and in the medical team, rectifying of legal loopholes should be considered.

Lateral position: a friendly surgical position for intramedullary nailing of tibial shaft fractures via infrapatellar approach

Background The conventional infrapatellar approach to intramedullary nailing of tibial fractures adopts the supine high-flexion knee position. However, this has disadvantages including difficulty in obtaining the proximal tibial anteroposterior view during intraoperative fluoroscopy, prolonged duration of fluoroscopy. Accordingly, the present study investigated the utility of the lateral position in the infrapatellar approach to intramedullary nailing of tibial shaft fractures. Methods The present study was a retrospective analysis of 112 patients who sustained closed tibial shaft fractures and treated with intramedullary nailing via the infrapatellar approach. Patients were divided into two groups according to surgical position: lateral or supine. The demographic and clinical data were collected and analyzed. Results There were 54 patients in the lateral and 58 in the supine position groups. The duration of surgery and fluoroscopy was shorter in the lateral group than the supine group (p < 0.05). Blood loss during surgery was lower in the lateral compared with supine position group (p < 0.05). The malunion rate was lower in the lateral position group as compared with the supine position group (p < 0.05); moreover, fewer surgical assistants were needed than in the supine group (p < 0.05). There were no significant differences in fracture healing time, other complications between the two groups (p > 0.05). Conclusions The lateral position was a more convenient choice for intramedullary nailing of tibial shaft fractures via infrapatellar approach.

Safety of patients and providers in lung cancer surgery during the COVID-19 pandemic

OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection—13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n = 20/21) or healthcare provider (n = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality.

Lateral Position: A Friendly Surgical Position for Intramedullary Nailing of Tibial Shaft Fractures Via Infrapatellar Approach

Purpose The purpose of this study was to investigate the utility of the lateral position in intramedullary nailing of tibial shaft fractures via the infrapatellar approach.Methods The present study was a retrospective analysis of 112 patients who sustained closed tibial shaft fractures and treated with intramedullary nailing via the infrapatellar approach. Patients were divided into two groups according to surgical position: lateral or supine. The demographic and clinical data were collected and analyzed. Results There were 54 patients in the lateral and 58 in the supine position groups. The duration of surgery and fluoroscopy was shorter in the lateral group than the supine group (p < 0.05). Blood loss during surgery was lower in the lateral compared with supine position group (p < 0.05). The malunion rate was lower in the lateral position group as compared with the supine position group (p < 0.05); moreover, fewer surgical assistants were needed than in the supine group (p < 0.05). There were no significant differences in fracture healing time, other complications between the two groups (p > 0.05). Conclusions The lateral position was a more convenient choice for intramedullary nailing of tibial shaft fractures via infrapatellar approach.

Clinical Desire for an Artificial Intelligence–Based Surgical Assistant System: Electronic Survey–Based Study

Background Techniques utilizing artificial intelligence (AI) are rapidly growing in medical research and development, especially in the operating room. However, the application of AI in the operating room has been limited to small tasks or software, such as clinical decision systems. It still largely depends on human resources and technology involving the surgeons’ hands. Therefore, we conceptualized AI-based solo surgery (AISS) defined as laparoscopic surgery conducted by only one surgeon with support from an AI-based surgical assistant system, and we performed an electronic survey on the clinical desire for such a system. Objective This study aimed to evaluate the experiences of surgeons who have performed laparoscopic surgery, the limitations of conventional laparoscopic surgical systems, and the desire for an AI-based surgical assistant system for AISS. Methods We performed an online survey for gynecologists, urologists, and general surgeons from June to August 2017. The questionnaire consisted of six items about experience, two about limitations, and five about the clinical desire for an AI-based surgical assistant system for AISS. Results A total of 508 surgeons who have performed laparoscopic surgery responded to the survey. Most of the surgeons needed two or more assistants during laparoscopic surgery, and the rate was higher among gynecologists (251/278, 90.3%) than among general surgeons (123/173, 71.1%) and urologists (35/57, 61.4%). The majority of responders answered that the skillfulness of surgical assistants was “very important” or “important.” The most uncomfortable aspect of laparoscopic surgery was unskilled movement of the camera (431/508, 84.8%) and instruments (303/508, 59.6%). About 40% (199/508, 39.1%) of responders answered that the AI-based surgical assistant system could substitute 41%-60% of the current workforce, and 83.3% (423/508) showed willingness to buy the system. Furthermore, the most reasonable price was US $30,000-50,000. Conclusions Surgeons who perform laparoscopic surgery may feel discomfort with the conventional laparoscopic surgical system in terms of assistant skillfulness, and they may think that the skillfulness of surgical assistants is essential. They desire to alleviate present inconveniences with the conventional laparoscopic surgical system and to perform a safe and comfortable operation by using an AI-based surgical assistant system for AISS.

Clinical Desire for an Artificial Intelligence–Based Surgical Assistant System: Electronic Survey–Based Study (Preprint)

BACKGROUND Techniques utilizing artificial intelligence (AI) are rapidly growing in medical research and development, especially in the operating room. However, the application of AI in the operating room has been limited to small tasks or software, such as clinical decision systems. It still largely depends on human resources and technology involving the surgeons’ hands. Therefore, we conceptualized AI-based solo surgery (AISS) defined as laparoscopic surgery conducted by only one surgeon with support from an AI-based surgical assistant system, and we performed an electronic survey on the clinical desire for such a system. OBJECTIVE This study aimed to evaluate the experiences of surgeons who have performed laparoscopic surgery, the limitations of conventional laparoscopic surgical systems, and the desire for an AI-based surgical assistant system for AISS. METHODS We performed an online survey for gynecologists, urologists, and general surgeons from June to August 2017. The questionnaire consisted of six items about experience, two about limitations, and five about the clinical desire for an AI-based surgical assistant system for AISS. RESULTS A total of 508 surgeons who have performed laparoscopic surgery responded to the survey. Most of the surgeons needed two or more assistants during laparoscopic surgery, and the rate was higher among gynecologists (251/278, 90.3%) than among general surgeons (123/173, 71.1%) and urologists (35/57, 61.4%). The majority of responders answered that the skillfulness of surgical assistants was “very important” or “important.” The most uncomfortable aspect of laparoscopic surgery was unskilled movement of the camera (431/508, 84.8%) and instruments (303/508, 59.6%). About 40% (199/508, 39.1%) of responders answered that the AI-based surgical assistant system could substitute 41%-60% of the current workforce, and 83.3% (423/508) showed willingness to buy the system. Furthermore, the most reasonable price was US $30,000-50,000. CONCLUSIONS Surgeons who perform laparoscopic surgery may feel discomfort with the conventional laparoscopic surgical system in terms of assistant skillfulness, and they may think that the skillfulness of surgical assistants is essential. They desire to alleviate present inconveniences with the conventional laparoscopic surgical system and to perform a safe and comfortable operation by using an AI-based surgical assistant system for AISS.

Identifying Barriers and Facilitators of Exoskeleton Implementation In The Operating Room

Introduction Members of the surgical team experience musculoskeletal (MS) symptoms that impact occupational health. Although the prevalence of MS symptoms in this population is well-recognized, limited interventions with sustained success exist for the operating room (OR) environment. The purpose of this work was to determine the facilitators of and barriers to exoskeleton technology in the OR, as a potential intervention to reduce upper-body MS pain and discomfort for surgical team members. Methods After providing informed consent, participants completed a two-part study: focus groups and a simulated laparoscopic skills task while wearing a passive arm-support exoskeleton (Levitate AirFrameTM). Seven surgical residents, four surgical technicians, and two attending surgeons participated in this study. A script including questions on technology adoption, supporting workers tasks/job, and safety and health (adapted from Kim et al., 2016) was used to guide each focus group. Content analysis of the focus groups was completed by three study team members to identify relevant themes from participants’ responses, and two raters coded all remaining sessions. Subsequently, nine participants completed repetitions of the Fundamentals of Laparoscopic Surgery peg transfer task for 10 minutes wearing the noted exoskeleton. Afterwards, their overall impressions of the exoskeleton were assessed using the System Usability Scale (SUS; Brooke, 1996). Results/Discussion Four main themes related to the adoption of exoskeletons in the OR were identified: characteristics of individuals, benefits, barriers, and intervention characteristics. Theme 1: Characteristics of individuals. It was noted that implementation of exoskeletons would require a champion at an institution to spearhead the efforts. Additionally, individual curiosity and awareness of MS ergonomics problems were found as facilitators of adoption. Theme 2: Benefits. Expected long-term benefits of an exoskeleton were mentioned. Specifically, stakeholders anticipated a decrease in MS symptoms and expected that it would help with workforce retention and prevention of early retirement. The user role that was identified to most benefit from exoskeletons were the surgical assistants ( n = 9). Theme 3: Barriers. Seven categories of barriers were found. Safety and sterility were major concerns in the OR. Main concerns included ensuring that the arm cuffs were not in the area of surgical scrub (i.e., below the elbows) and the added bulk to wear inside the surgical gown. Furthermore, the factors of familiarity, perception, buy-in, and immediate results were noted to influence the use of an exoskeleton. Theme 4: Intervention characteristics. The theme of intervention characteristics was identified separately from benefits and barriers, as the categories in this theme could either help facilitate or hinder the adoption of exoskeletons in the OR. Workers reported that investment, specifically monetary, and maintenance of the equipment would likely influence wide-spread adoption. Usability of the exoskeleton was indicated as having a large influence on adoption. Workers in all roles noted that whether they adopt the exoskeleton during surgical procedures would depend on usability. The mean SUS score for the exoskeleton tested was 82.2 out of 100 ( SD = 7.9), which was within the acceptable range of usability. Passive exoskeleton technology has the potential to minimize MS symptoms and fatigue for the surgical team (Liu et al., 2018). The current work identified themes for adopting exoskeletons in the OR, and thus builds a better understanding of facilitators of and hinderances to stakeholders using this technology. Exoskeletons were suggested as having the potential to improve workforce retention and decrease MS symptoms. These results suggest that the use of arm-support exoskeletons can be valuable, though barriers such as cost and team member buy-in need to be addressed. Acknowledgements. This work was supported by Cooperative Agreement T42 OH008455, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or DHHS. The exoskeleton used in this study was loaned by the Levitate company; the company had no involvement in study design, analysis, or interpretation, nor the decision for publication.

Radiation Dose to the Eye Lens Through Radiological Imaging Procedures at the Surgical Workplace During Trauma Surgery

Background: Due to the drastic reduction of the eye lens dose limit from 150 mSv per year to 20 mSv per year since 2018, the prospective investigation of the estimated dose of the eye lens by radiological imaging procedures at the surgical site during trauma surgery in the daily work process was carried out. This was also necessary because, as experience shows, with changes in surgical techniques, there are also changes in the use of radiological procedures, and thus an up-to-date inventory can provide valuable information for the assessment of occupationally induced radiation exposure of surgical personnel under the current conditions. Methods: The eye lens radiation exposure was measured over three months for five trauma surgeons, four hand surgeons and four surgical assistants with personalized LPS-TLD-TD 07 partial body dosimeters Hp (0.07). A reference dosimeter was deposited at the surgery changing room. The dosimeters were sent to the LPS (Landesanstalt für Personendosimetrie und Strahlenschutzausbildung) measuring institute (National Institute for Personal Dosimetry and Radiation Protection Training, Berlin) for evaluation after 3 months. The duration of the operation, occupation (assistant, surgeon, etc.), type of surgery (procedure, diagnosis), designation of the X-ray unit, total duration of radiation exposure per operation and dose area product per operation were recorded. Results: Both the evaluation of the dosimeters by the trauma surgeons and the evaluation of the dosimeters by the hand surgeons and the surgical assistants revealed no significant radiation exposure of the eye lens in comparison to the respective measured reference dosimeters. Conclusions: Despite the drastic reduction of the eye lens dose limit from 150 mSv per year to 20 mSv per year, the limit for orthopedic, trauma and hand surgery operations is well below the limit in this setting.