BACKGROUND: Review of medical malpractice case law and health professions review and appeals board (HPRAAB) decisions related to appendectomy cases can help inform risk mitigation strategies in perioperative management a...BACKGROUND: Review of medical malpractice case law and health professions review and appeals board (HPRAAB) decisions related to appendectomy cases can help inform risk mitigation strategies in perioperative management and improve patient outcomes and surgical practice. METHODS: This retrospective study was performed using decisions published in the publicly accessible Canadian Legal Information Institute database (CanLii). Descriptive statistics were recorded and presented as number and percentage for categorical data. RESULTS: The search identified 299 cases, 15 of which (including 3 HPRAAB decisions) met study criteria spanning 1986 to 2024. Allegations of malpractice were most commonly related to diagnostic error including both misdiagnosis and delayed diagnosis (n = 6/15, 40.0%), inadequate monitoring or follow-up (n = 4/15, 26.7%), poor decision-making in complicated post operative courses (n = 2/15, 13.3%), inadequate documentation (n = 2/15, 13.3%), and incorrect organ removal (n = 1/15, 6.7%). CONCLUSIONS: Analysis of case law and HPRAAB decisions involving allegations of malpractice in the performance of appendectomies has yielded valuable insight into multiple areas of improvement for patient care.
BACKGROUND: High-quality preoperative goals of care (GOC) documentation should address prognosis, goals and values, treatment options, and justification of a preferred treatment option. A reproducible method for evaluati...BACKGROUND: High-quality preoperative goals of care (GOC) documentation should address prognosis, goals and values, treatment options, and justification of a preferred treatment option. A reproducible method for evaluating note quality is critical for quality improvement. We sought to adapt a pre-existing rating rubric for preoperative GOC documentation and evaluate its interrater reliability (IRR). METHODS: We analyzed preoperative GOC notes from frail Veterans considering elective outpatient surgery at 5 Veterans Affairs Medical Centers. IRR was assessed using percent agreement and Cohen's kappa across 4 domains and overall quality. RESULTS: 215 notes (April 2022 - July 2023) were included. Cohen's kappa ranged from 0.66 to 0.91 with percent agreement of 80.1% to 94.0%. The pooled kappa across domains was 0.82, indicating substantial to almost perfect agreement. CONCLUSIONS: Iterative refinement produced a reliable rubric with at least substantial IRR, supporting its use for independent rating and quality improvement. Domain-specific variability highlights opportunities for further rubric refinement and rater training.
BACKGROUND: Postoperative abdominal and shoulder pain, nausea, and vomiting are among the most common complications following laparoscopic surgery, often necessitating increased use of analgesics and antiemetics. This st...BACKGROUND: Postoperative abdominal and shoulder pain, nausea, and vomiting are among the most common complications following laparoscopic surgery, often necessitating increased use of analgesics and antiemetics. This study aimed to compare the effects of nitrous oxide (NO) and positional maneuvers on pain intensity, incidence of nausea and vomiting, and analgesic requirements after laparoscopic surgery. MATERIALS AND METHODS: This double-blind randomized clinical trial was conducted on 126 elective patients scheduled for laparoscopic cholecystectomy. The patients were randomly assigned into three groups of 42 individuals each: one group received NO, another received a combination of positional maneuver and pulmonary recruitment, and the third served as the control group. Pain intensity, nausea, vomiting, and time to first analgesic request were assessed at 6, 12, and 24 h postoperatively. Data were analyzed using ANOVA, Chi-square, and Fisher's exact tests. A p-value of less than 0.05 was considered statistically significant. All analyses were performed using SPSS software, version 24. RESULTS: The results showed that the NO group experienced the lowest intensity of abdominal and shoulder pain at all time points, and the time to first analgesic request was significantly longer in this group than the others (p < 0.05). Additionally, the incidence of nausea and vomiting was lower in the intervention groups than in the control group, and this difference was statistically significant (p < 0.05). Among the demographic variables, gender was the only factor associated with the occurrence of complications; females experienced vomiting more frequently than males. CONCLUSION: Both nitrous oxide and positional maneuvers effectively reduced postoperative pain and gastrointestinal complications, with NO showing greater efficacy in minimizing symptoms and delaying analgesic need.
BACKGROUND: Despite increases in same-day discharge after mastectomy, there are few studies assessing its implications in the elderly. Our institution initiated enhanced recovery after surgery (ERAS®) principles emphasiz...BACKGROUND: Despite increases in same-day discharge after mastectomy, there are few studies assessing its implications in the elderly. Our institution initiated enhanced recovery after surgery (ERAS®) principles emphasizing outpatient mastectomy in 2017. This study assessed the effect of introducing outpatient mastectomy on outcomes in the elderly. METHODS: A prospective database was retrospectively reviewed for patients ≥70 years old undergoing mastectomy with or without implant-based reconstruction from 2015 to 2023. Patients from 2015 to 2016 were pre-ERAS®, and 2017-2023 were post-ERAS®. RESULTS: Out of 139 patients, 85 were post-ERAS® and 54 were pre-ERAS®. Of the post-ERAS®, 65% were outpatient versus 17% of pre-ERAS® patients (p < 0.001). Complication rates were no different between groups (33% vs 33%, p = 0.88), even when separated by type of complication, including those requiring operative intervention (14% vs 13%, p = 0.85). CONCLUSIONS: Outpatient mastectomy can be implemented in the elderly without an increase in morbidity, making it safe and practical in this population.
BACKGROUND: Small bowel diverticula are uncommon, often asymptomatic, and typically discovered incidentally. Small bowel diverticulitis with perforation is even more rare and potentially life-threatening. METHODS: Given...BACKGROUND: Small bowel diverticula are uncommon, often asymptomatic, and typically discovered incidentally. Small bowel diverticulitis with perforation is even more rare and potentially life-threatening. METHODS: Given the paucity of literature and lack of management guidelines, a single-center retrospective study was conducted from 2015 to 2024 on patients diagnosed with small bowel diverticulitis. RESULTS: Of 32 patients with small bowel diverticulitis, 14 (44%) had perforation. Eight of these (57%) were managed operatively, including two initially treated non-operatively. All 32 patients received antibiotics with gram-negative and anaerobic coverage. Interestingly, about 34% of the patients in our sample were diagnosed in the year 2022 alone. Patients with perforated small bowel diverticulitis had a longer mean length of stay at 10.2 days in comparison to those without at 4.9 days (p = 0.056). All patients with small bowel diverticulitis without perforation did not need any surgical intervention and were managed nonoperatively (p = 0.0001). All patients who underwent surgery had abdominal pain and CT findings of contained perforation or extraluminal air/fluid. CONCLUSIONS: This is one of the largest single center studies in the US focusing on perforated small bowel diverticulitis. For patients without perforation, they were all managed non-operatively. The study highlights the rarity of the condition and offers insight into its presentation and management over nearly a decade.
OBJECTIVE: Given the inadequacy of current evaluation systems for laparoscopic training, this study aims to develop a multidimensional competency framework for surgical residents. The framework is intended to identify ke...OBJECTIVE: Given the inadequacy of current evaluation systems for laparoscopic training, this study aims to develop a multidimensional competency framework for surgical residents. The framework is intended to identify key indicators that distinguish excellent performance and better support resident training. METHODS: Based grounded theory and the Iceberg Model, interviews with 15 specialists and 21 residents informed the competency framework. For validation, residents were divided into "excellent" and "average" cohorts, undergoing double-blind competency scoring and comparative analysis. RESULTS: The finalized competency framework comprises 47 specific competency characteristics across four themes: knowledge, skills, traits, and motives. Comparative analysis revealed four key competency characteristic (Surgical Procedures, Self-awareness, Professional Ethics, and Optimism & Confidence) that significantly distinguished excellent from average residents. CONCLUSION: By integrating explicit and implicit competencies, this model provides a novel evaluation tool for identifying and cultivating surgical talent, offering a paradigm shift for quality assurance in standardized laparoscopic residency programs.
Geller JE, Fonteh A, Cheruvu S
… +3 more, Doppalapudi A, Annesi CA, American Journal of Surgery Student and Resident Scholar (STARS) Research Delegation
BACKGROUND: Autologous breast reconstruction (ABR) offers superior aesthetics but carries significant risks of wound healing complications. We aimed to identify modifiable perioperative factors associated with these comp...BACKGROUND: Autologous breast reconstruction (ABR) offers superior aesthetics but carries significant risks of wound healing complications. We aimed to identify modifiable perioperative factors associated with these complications to optimize surgical outcomes. METHODS: We analyzed the ACS-NSQIP database (2011-2022) for patients undergoing immediate ABR. Multivariable regression identified independent associations with 30-day wound complications. RESULTS: Among 7489 patients, wound complications occurred 634 times: superficial surgical site infection (SSSI, n = 358), deep incisional infection (DII, n = 87), dehiscence (n = 126), and organ space infection (OSI, n = 63). Higher BMI was significantly associated with all wound complication types (OR 1.1; p ≤ 0.001). Smoking was independently associated with SSSI (OR 1.6; p = 0.024) and DII (OR 2.3; p = 0.033). Diabetes (OR 3.3; p < 0.001) and dyspnea (OR 3.6; p = 0.022) were significantly associated with increased OSI risk. Wound class >1 was associated with SSSI (OR 1.5) and DII (OR 2.4). CONCLUSION: BMI, smoking, and diabetes are critical and potentially modifiable risk factors associated with wound complications in ABR. Preoperative optimization could reduce these adverse events and improve reconstructive success.
BACKGROUND: We aimed to compare open, laparoscopic, and robotic cholecystectomy, and examine how country income levels modify these associations. METHODS: We conducted a systematic review and meta-analysis of randomized...BACKGROUND: We aimed to compare open, laparoscopic, and robotic cholecystectomy, and examine how country income levels modify these associations. METHODS: We conducted a systematic review and meta-analysis of randomized and observational studies from major databases through November 2024. We analyzed data from 85 studies comprising over 7.5 million patients. We utilized random-effects models to estimate risk ratios (RR) and mean differences (MD), and applied meta-regression to assess the influence of World Bank income classifications. RESULTS: Laparoscopic cholecystectomy (LC) significantly reduced mortality (RR 0.16; 95% CI: 0.13-0.18), complications (RR 0.46), and length of stay (-4.08 days) versus open surgery. Robotic surgery yielded no significant clinical benefits over LC. Meta-regression revealed that the mortality benefit of LC was significantly greater in low- and middle-income countries than in high-income nations. CONCLUSIONS: LC demonstrates superior safety and efficacy compared to open techniques, especially in resource-limited settings. Based on the available evidence, no demonstrable difference in outcomes was observed between robotic and laparoscopic approaches.
BACKGROUND: Entrustable Professional Activity (EPA) evaluations are the emerging foundation for providing resident feedback and assessing practice-readiness. No studies to date have utilized artificial intelligence to co...BACKGROUND: Entrustable Professional Activity (EPA) evaluations are the emerging foundation for providing resident feedback and assessing practice-readiness. No studies to date have utilized artificial intelligence to compare qualitative feedback with quantitative scoring. METHODS: This single-institution retrospective analysis applied natural language processing (NLP) models to elucidate keywords associated with resident entrustability. Resident EPA micro-assessments from 7/6/2023-12/3/2024 across post-graduate year levels were included. NLP algorithms and Spearman's correlations isolated keywords associated with entrustability and discrepancies between attending and resident-assigned scores. RESULTS: One-thousand evaluations focused on gallbladder, intestinal disease, hernia, and acute severe illness cases. Lower entrustability themes included camera navigation, following the case, and retraction. Higher entrusted residents were described as "independent" and "safe." Attendings who rated residents higher than residents' self-ratings mentioned complex pathologies and emotional aspects. CONCLUSIONS: This AI-based tool can be integrated across residency programs to identify characteristics of entrustable residents and help provide a valuable roadmap for development.
BACKGROUND: Medical reversals occur when previously accepted interventions are later found to be ineffective or harmful through high-quality evidence. As ventral hernia (VH) management evolves, the number of randomized c...BACKGROUND: Medical reversals occur when previously accepted interventions are later found to be ineffective or harmful through high-quality evidence. As ventral hernia (VH) management evolves, the number of randomized controlled trials (RCTs) has also grown substantially. We evaluated how these trials align with current guidelines recommendations. METHODS: A systematic review of all VH-related RCTs published between 2014 and 2025 was conducted. Trial conclusions were compared with the recommendations of four major guidelines, and outcomes were categorized as: medical reversal, no change, not applicable, or published before guideline issuance. RESULTS: A total of 96 RCTs generated 99 unique recommendations, yielding 396 guideline comparisons. Of these, 224 (56.6%) were not applicable and 76 (19.2%) comparisons were excluded by date. Among the remaining comparisons, 36 (37.5%) contradicted guideline recommendations, while 60 (62.5%) supported them. CONCLUSIONS: Most RCTs investigated areas not addressed by current guidelines. Of relevant trials, one-third resulted in a medical reversal, emphasizing the need for continued high-quality research to guide practice and optimize patient outcomes.
OBJECTIVE: Workload equity is a factor critical in maintaining resident well-being but remains inadequately addressed via duty-hour restrictions alone. We evaluated a Resident Call Points (RCP) System's effectiveness in...OBJECTIVE: Workload equity is a factor critical in maintaining resident well-being but remains inadequately addressed via duty-hour restrictions alone. We evaluated a Resident Call Points (RCP) System's effectiveness in promoting equity in residency training by reducing disparities in workload variance and improving duty hour compliance. METHODS: A single-site retrospective analysis of the call burden of 94 junior neurosurgical residents over 22 years was conducted. The RCP system is a weighted call-allocation framework used to measure and balance resident call burden quantitatively by assigned shifts a specific point value. Equity of workload distribution and overall call burden were the primary outcomes. Equity was measured using the variance (statistical spread) of RCPs while call burden was measured with the median RCP. Two groups: G1; pre-RCP period (2003-2011), and G2; post-RCP period (2012-2025) were analyzed and compared based on median RCP, RCP variance, and accredited survey-reported duty-hour compliance. RESULTS: After implementation of the RCP system, overall variance significantly decreased in G2 compared to G1, indicating greater equity in workload distribution. RCP median was significantly increased between G2 and G1 for PGY-3 only, indicating an increased workload for that specific training year. Sub-analysis did not reveal differences in workload between PGY-2 and PGY-3 in G2. Reported duty-hour violations decreased from 34% (18/53) to 11.1% (10/90) post-implementation (p < 0.001). CONCLUSION: The RCP system likely promotes equity in the call schedule by significantly reducing workload variance and is associated with improved resident compliance with duty-hours. By promoting fairness and addressing workload equity, the RCP system may provide a reproducible framework for improving duty-hour compliance in graduate medical education.