General Surgery News ( August 2020)

FIR ST L O O K The American Society of Breast Surgeons Virtual Meeting: Page 3

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

August 2020 • Volume 47 • Number 8

Cancel? Postpone? Go Virtual?

Hindsight: If Only We Knew Then

Behind the Tough Decisions Societies Are Making About Meetings During COVID-19

Surgeons Reminisce About Lessons Learned on Life, Surgical Careers

By MONICA J. SMITH

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n early spring, as the scope of the COVID-19 pandemic sank in, membership organizations had some hard decisions to make about their annual meetings: Postpone to a later date? Cut your losses and cancel? Or switch to a virtual format?

“We considered all of those,” said Jill Dietz, MD, the director of breast operations at University Hospitals Cleveland Medical Center, and president of the American Society of Breast Surgeons (ASBrS).

Initially, they discussed moving the early May meeting to November, but that would have complicated their financial obligation with the Las Vegas meeting site. It would have resulted in planning for two meetings at once, and would have rendered null the research selected for presentation in 2020.

“We receive at least 300 abstracts every year and accept

By MONICA J. SMITH

New Orleans—Hindsight, as they say, is 20/20, and few of us pass through life without wondering how things might have been different if we’d known then what we know now.

But as Laura Witherspoon, MD, observed, reflecting on the panel topic, “Things I Wish I Had Known,” “that’s kind of like wishing your life away, because everything you didn’t know at the beginning and learn along the way is your life’s story.”

She and three other surgeons shared their memories, advice and encouragement at the 2020 Southeastern Surgical Congress.

Continued on page 9

THE RESIDENT CORNER

Continued on page 28

MONEY MATTERS

Stories of Surgery

Surprise Medical Bills: An Overview

By BARRET HALGAS, MD

Unexpected Out-of-Network Charges

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ost will recall that in the he Greek epic poem, “The he Odyssey,” the warrior Odysseus eus is desperately trying to return n home after war. As the gods on Mount Olympus argue over his fate, the warrior fights to be reunited with his wife and son, a very familiar narrative in ancient Greek literature (nostos). In the 17th century, nostos became medical terminology when the suffix “–algia” was added and homesick soldiers at war were diagnosed with nostalgia. Historians have always hesitated to assign authorship to a single writer named Homer. Rather, the collection of poems is more

By VICTORIA STERN

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ore than $28,000 to remove an appendix, almost $94,000 for spinal surgery, over $500,000 for lifesaving dialysis treatment—these figures represent just a few of the unexpected medical bills patients have received, according to Kaiser Health News’ “Bill of the Month” column.

Concerns about surprise bills continue to mount as more people share their stories and as researchers dig into the extent of the problem.

“Surprise medical bills can be financially devastating,” said Karen Joynt Maddox, MD, MPH,

Continued on page 10

S URGEONS’ LOU N G E

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Bariatric Surgery Complications

Continued on page 27

EXTENDED HERNIA COVERAGE

OP IN ION

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The ‘Holy Grail’ of Lap Chole

ON THE SPOT

19 The Art of Herniology, Part 2 facebook.com/generalsurgerynews

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@gensurgnews

OPINION

A Tribute to Health Care’s First Responders

By HENRY BUCHWALD, MD, PhD

I

n my June 2020 column, I briefly reviewed 14 prior major pandemics and epidemics. In the recorded his-tories of these events, doctors and other er health care personnel were always “first responders,” often at great personal peril. COVID-19 has been no exception; it has been our time to be first responders.

This article reviews health care responses from both coasts and from the heartland, as well as the leadership provided by the American College of Surgeons. I would like to stress that these few examples are drawn from the excellent Continued on page 30

FIRST LOOK

AUGUST 2020 / GENERAL SURGERY NEWS

First Look: American Society of Breast Surgeons 2020 (Virtual) All Articles by MONICA J. SMITH

Three Nomograms Reviewed in Study

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everal published nomograms can help lp predictt which patients with clinically node-positive positivee breast cancer will convert to pathologically gicallyy node-negative disease after neoadjuvant chemotherapy. New research shows that three hreee models perform well and could be used d in surgical decision making regarding staging aging the axilla.

“When patients who undergo NAC C [neoadjuvant chemotherapy] are node-negative, tive, they undergo sentinel lymph node biopsy (SLNB),, and when they are clinically node-positive, ive, they undergo axillary dissection. But if thesee clinically node-positive patients convert to nodenegative, SLNB is acceptable,” said John n Davis Jr., MD, a breast surgical oncology ogy fellow at Mayo Clinic in Rochester, Minn. nn.

In a comparison of three nomograms, ms, one developed by Mayo Clinic and two wo from the University of Texas MD Anderrson Cancer Center (MDACC) in Houston, on, Dr. Davis and his colleague retrospectively ely reviewed 581 patients who underwent surgical treatment with axillary staging at Mayo Clinic between 2008 and 2019, usingg the nomograms to predict pathologic complete mplete

(pCR), defined as ypN0 status. rresponse re sponse (p By su subtype, pCR was found most commonly in patients with HER2commo positive disease, at 69%, followed by patients with triple-negative disease, at patien 47%, and a those with estrogen receptor (ER)-positive disease, at 24%.

(ER)To evaluate the performance of the no nomograms, the researchers established a nominal threshold of 50% or higher. Mayo Clinic’s model, which had M the highe highest sensitivity at 89.6%, outperformed the other oth two in assigning a probability of ypN0 of le less than 50% status to ypN-positive patients patients.

The two MDACC nomograms, which had highe higher specificity than Mayo Clinic’s model, iidentified 62% of ypN0 patients as ha having at least a 50% chance of having negative nodes. The Mayo hav Clinic model predicted negaC tive nodes in only 41% of these t patients. p ““If we took a look at the tumor biology, we see that the ER-posib olo bi tive, HER2-negative group actually

MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons.

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had the highest sensitivity for each nomogram, and the HER2-positives and triple-negatives had a greater specificity,” Dr. Davis said.

The investigators concluded that the number of suspicious nodes found on ultrasound (a feature of one of the MDACC nomograms) does not correlate with pCR, that all three models predict nodal response to NAC, and that they work best in patients with HER2positive and triple-negative disease.

Dr. Davis presented his research at the American Society of Breast Surgeons’ Virtual Education Series, held online this year in lieu of the annual meeting. At the conclusion of his presentation, moderator Brigid Killelea, MD, an associate professor of surgery at Yale School of Medicine in New Haven, Conn., posed a practical question.

“How would you use this information in clinic to talk with patients?” she asked.

Dr. Davis suggested they could be a helpful visual aid for patients. “If we use these nomograms in front of them on a computer, they can see specific numbers of predicted probability that they will have a pCR in their axilla. So when we’re discussing whether to do a SLNB or axillary dissection, this can help us point in one direction or the other.” continued on the following page

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FIRST LOOK

GENERAL SURGERY NEWS / AUGUST 2020

Lymphedema Prevention Surgery Shows Promise

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urgery may be a way to reduce the risk for lymphedema, a chronic and potentially devastating condition that approximately 40% of breast cancer patients at highest risk for it will develop. The surgery does initially increase operating time, but this decreases as surgeons gain experience, according to new research.

At Cleveland Clinic in Ohio, lymphedema prevention surgery (LPS), defined as immediate lymphatic reconstruction at the time of axillary dissection, consists of several components performed by either the breast surgeon or reconstructive surgeon.

“Our approach includes axillary reverse mapping using isosulfan blue; a refined axillary lymph node dissection (ALND), in which we use loop magnification to allow us to better identify and preserve lymphatics and veins for use by the reconstructive surgeons; microsurgical lymphatic venous bypasses (LVBs); and confirmation of patency,” said Kristina Shaffer, MD, a breast surgical oncology fellow at Cleveland Clinic.

“This approach can help prevent lymphedema; however, we still need to consider practical aspects of incorporating this technique. We hypothesized that operative times would improve with experience,” she said.

To test their hypothesis, Dr. Shaffer and her colleagues evaluated operative time data from 88 patients who underwent LPS at their institution between 2016 and 2019. Breast surgeon time consisted of the oncologic breast surgery, ALND and axillary reverse mapping, and reconstructive surgeon time accounted for reconstruction, LVB, confirmation of patency and closure.

Breast surgeon times remained stable throughout the

study period, but among reconstructive surgeons operating time dropped significantly. “For example, in the patients who did not undergo reconstruction, the mean time per anastomosis decreased from 212 minutes to 87 minutes,” Dr. Shaffer said. “We saw a similar trend in the prosthetic reconstruction group.”

While minutes decreased, the total number of anastomoses performed increased, from four per year at the beginning of the study to 70 per year. The average number of LVBs per patient also increased, from one to two, with a concurrent decrease in the time required per LVB. A limitation of the study is that it evaluated data only on patients who successfully underwent LPS; thus, there is no information on failure rates.

This study does indicate LPS may be a practical approach to reducing lymphedema risk.

“OR times decreased more than twofold for individual anastomoses; we saw twice the number of LVB performed per patient; and the total number of LVB increased more than 17 times,” Dr. Shaffer said.

She attributed this progress not just to increased ability among reconstructive surgeons, but also to breast surgeons becoming skillful at preserving a greater number of suitable lymphatics and veins, and increased collaboration between teams.

“This is a significant finding in terms of allocating resources and ensuring efficient use of ORs in medical centers offering LPS,” Dr. Shaffer said.

Dr. Shaffer reported her research at the American College of Breast Surgeons’ Virtual Education Series, presented online this year in lieu of the annual meeting.

Data Support ‘No Ink on Tumor’ as Margin Guideline

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meta-analysis has shown that absolute rates of local recurrence in breast cancer patients unergoing breast-conserving surgery have fallen over time across a range of margin widths, and findings support the current clinical guideline definition of a negative margin as no ink on tumor.

To evaluate how rates of local recurrence (LR) have changed over time and the effect that changes in treatment paradigms have had on LR using various margin definitions, Chirag Shah, MD, the director of Breast Radiation Oncology at Cleveland Clinic in Ohio, and his colleagues from multiple institutions conducted a metaanalysis of studies published between 1996 and 2016.

Their meta-analysis included 38 studies with a total of 54,502 patients. Margins fell into nine cohorts including: • positive margins; • margins ranging 0 to 1 mm, 0 to 2 mm and 0 to 5 mm; • margins of 5 mm or less, more than 2 mm, 0 mm and more than 5 mm; and • unknown margins.

“Some studies provided data on more than one of these margin cohorts,” Dr. Shah said.

Margins were defined as positive if invasive cancer or ductal carcinoma in situ were seen at the microscopic surgical margin, and negative if there was either no tumor on ink or a minimum distance from tumor on ink. The researchers used Bayesian logistic mixed effects regression to evaluate the risk of LR in relation

to margin status and the four enrollment periods: 1980, 1990, 2000 and 2005.

“The absolute rates of LR decreased for all margin definitions over each of the enrollment periods, which also led to an absolute reduction between margin definitions,” Dr. Shah said.

Relative rates of recurrence were stable despite decreasing rates of LR for each cohort. “Comparing no tumor on ink to less than 5 mm, the relative rate of LR between margin definitions was 0.62, 0.61, 0.61 and 0.61 for each of the four enrollment periods. This was seen for all relative rate combinations,” Dr. Shah said.

The study did not evaluate the individual impact of different improvements in treatment over time.

Dr. Shah and his colleagues concluded that their research supports the use of no tumor on ink as an appropriate margin guideline, and that it suggests many reexcisions for close margins can be avoided.

“Not all positive margins are created equal; some may be positive on a pathology report but actually clinically negative. I think there’s always a risk‒benefit discussion in terms of the data we have available, and the dangers of reexcising compared with not reexcising knowing that we will not find cancer in some of these patients who undergo additional surgery,” Dr. Shah said.

He presented the research at the American Society of Breast Surgeons’ Virtual Education Series, held in lieu of the annual meeting.

Glass Ceiling Largely Broken in Breast Surgery

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omen continue to constitute a minority at the bulk of surgical conferences, but one annual meeting suggests the glass ceiling is not unbreakable.

The proportion of women in surgery skyrocketed from 3.6% in 1980 to 25% in 2019, but they lag in leadership positions and research. Now the specialty of breast surgery, which shows a strong patient preference for female surgeons, is a bit different.

To investigate trends in female representation among breast surgeons, Jenny Chang, MD, a resident physician at Cleveland Clinic, Sharon Lum, MD, and their colleagues at Loma Linda University in California, reviewed materials from the annual meetings of the American Society of Breast Surgeons (ASBrS) from 2009 to 2019, looking at committee leadership, scientific presentations and other meeting sessions.

They found the proportion of female committee members and chairs increased significantly each year, by 3.2% (P=0.005) and 5.9% (P=0.03), respectively.

Over the 10-year study period, women accounted for 44.8% of the society’s board of directors, nearly 55% of all committee memberships and 42% of the chairs of those committees.

“Furthermore, though a global study of 1.5 million medical papers found only 35% had women in authorship positions, women comprised a majority participation in all scientific presentations at the ASBrS meeting,” Dr. Chang said.

Among presenters, women made up 77% of oral presentations and 74% of quick shot presentations, and were first authors on 75% of oral, 75% of quick shot and 71% of poster abstracts. In addition, 70% of oral presentations, 67% of quick shot presentations and 60% of poster abstracts listed a woman as the senior author.

“Subsequent publication rate of materials presented at ASBrS fell annually from 51% in 2009 to 28% in 2019, but female senior authorship was associated with a higher manuscript publication rate than male senior authorship,” Dr. Chang said. Among the manuscripts that were published, 71% of first authors and 64% of senior authors were women.

Dr. Chang acknowledged a few limitations of the study. It did not analyze other manifestations of diversity, such as race and ethnicity, area of expertise or geography; it was limited to a binary classification of gender, which could leave out gender minorities and nonbinary individuals; and it was not always possible to identify the gender of the presenters.

“Nonetheless, this paper suggests that within the realm of general surgery, breast surgery has distinctively shattered the glass ceiling. The ASBrS should be an example for others to follow,” Dr. Chang said.

She noted that the ASBrS has intentionally and actively recruited women into leadership positions. “I think that has a very strong downstream effect on increasing participation rates of women and paving the way for young female trainees.”

Dr. Chang presented her research as part of the ASBrS’s Virtual Education Series, which was held online this year in lieu of the annual meeting. ■

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GENERAL SURGERY NEWS / AUGUST 2020

Clinical Scenarios in Bariatric Surgery: Lesser-Known Complications Case 1: Omental Abscess After Laparoscopic Roux-en-Y Gastric Bypass

Welcome to the August issue of The Surgeons’ Lounge. In this issue, Matyas Fehervari, MD, PhD, MRCS, a general and bariatric surgery resident at Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College, in London, interviews Haris Khwaja, MD, DPhil (Oxon), FRCS, a consultant bariatric surgeon, also at Chelsea and Westminster Hospital and Imperial College, about two patient scenarios regarding inflammation and infarction of fat and its implications in bariatric surgery.

We look forward to our readers’ questions, comments and interesting cases to present.

Sincerely, CS Samuel Szomstein, MD, FACS ge Editor, The Surgeons’ Lounge Szomsts@ccf.org

This case involved a 41-year-old woman with an American Society of Anesthesiologists physical status classification score of III and a complex medical history, including severe asthma with prednisolone requiring, on average, two to three hospital admissions per year and dilated cardiomyopathy due to New York Heart Association class III cardiac failure diagnosed when she was 39 years of age. Her left ventricular function improved (ejection fraction, 48%) once a bi-ventricular pacing device and an intracardiac defibrillator were fitted in 2017. Further relevant medical history included obstructive sleep apnea on continuous positive airway pressure ventilation overnight, steroid-induced borderline diabetes mellitus and severe gastroesophageal reflux disease (GERD).

This patient’s case was discussed at the bariatric multidisciplinary team meetings, assessed in the high-risk anesthetic clinic, and cleared for bariatric surgery by the anesthetic, surgical, dietetic, and psychology teams. In view of her brittle asthma, her prednisolone dosage was increased to 20 mg per day for one week before surgery.

She underwent an elective laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2019 by Dr. Khwaja.

Intraoperative findings included the presence of hepatomegaly due to non-alcoholic steatohepatitis and a very thick greater omentum. The greater omentum was split using the LigaSure device (Medtronic) perpendicular to the transverse colon. A triple-stapled jejunojejunostomy was created followed by the creation of an 8-cm–long lesser curve–based gastric pouch. A circular-stapled gastrojejunal anastomosis was created with the Orvil device (25 mm) (Medtronic), using a 3.8-mm staple height. Both Petersen’s and jejunojejunostomy mesenteric defects were closed with a 15-cm permanent V-lock suture.

The immediate postoperative course was unremarkable, with the patient spending one night in the highdependency unit, as planned, and then discharged to home from the surgical floor on postoperative day 3. She attended clinic one week later for assessment and was clinically well. At three weeks postoperatively, she attended clinic again, at her request, complaining of epigastric pain; a CT scan done that day showed omental infarction of approximately 10×8 cm (Figure 1). In view of the abdominal pain, she was admitted for analgesia and antibiotics, and she remained on 20 mg of prednisolone for

Figure 1. CT scan showing an area of omental infarction of approximately 10×8 cm.

Figure 2. CT scan demonstrating some liquefactive necrosis of the infarcted omentum.

her asthma. Her white blood cell count and inflammatory markers failed to improve, and 10 days after this admission, she developed fevers and shivers as well as worsening abdominal pain. A CT scan demonstrated some liquefactive necrosis of the infarcted omentum (Figure 2). This was not amenable to radiological percutaneous drainage, and, in view of her sepsis, the decision was made to perform diagnostic laparoscopy, during which an omental abscess was drained. One hundred milliliters of pus was drained, after which the patient made an uneventful recovery.

Case 2: Mesenteric Panniculitis and Bariatric Surgery This case involved a 56-year-old woman with a BMI of 41 kg/m2 and medical history of mild asthma, impaired glucose tolerance, sciatica, depression and three cesarean deliveries. She also had non-alcoholic fatty liver disease and a history of excess alcohol consumption. She had been extensively investigated by the hepatology team, and it was believed that she had no significant liver disease. The patient was scheduled for an elective LRYGB. During surgery, it was noted that she had evidence of extensive mesenteric panniculitis, and the proximal small bowel was adherent to adjacent small-bowel loops as well as to the transverse mesocolon. After a trial dissection, it was determined that there was significant mesenteric panniculitis and jejunitis, and a sleeve gastrectomy was performed, as the patient had been consented for both procedures. She made an uneventful recovery from surgery and was discharged on postoperative day 2.

In view of the surgical findings, a CT scan was performed six weeks after surgery that showed evidence of enterocolitis and mesenteric panniculitis with a well-formed sleeve (Figure 3). The patient was referred to a gastroenterologist for further management. She had no acid reflux and has been enrolled in a five-year endoscopic surveillance program in view of the recent reports of an increased incidence of Barrett’s esophagus in patients undergoing sleeve gastrectomy.

Figure 3. CT scan showing evidence of enterocolitis and mesenteric panniculitis with a well-formed sleeve.

SURGEONS’ LOUNGE

AUGUST 2020 / GENERAL SURGERY NEWS

Interview With Haris Khwaja, MD Dr. Fehervari: What made you choose these particular cases for the purpose of this interview?

Dr. Khwaja: Discussions around complications of weight loss surgery are usually focused on bleeding, anastomotic/staple leaks and internal hernias. There is very little in the published literature on omental infarction/abscess after LRYGB or the implications of mesenteric panniculitis in bariatric surgery. Indeed, one of the most obvious problems of patients undergoing bariatric surgery is the extreme amount of visceral and subcutaneous adipose tissue. This may seem surgically less important, but these cases illustrate that the large amount of fatty tissue itself can lead to significant problems and have implications on the outcome or choice of operation. The first patient had very severe cardiac and respiratory disease, preferred LRYGB over laparoscopic sleeve gastrectomy (LSG), and yet she suffered from a complication perhaps best described as a “disease of the fat.” The second patient had to be converted intraoperatively to LSG due to extensive mesenteric panniculitis.

Dr. Fehervari: In the first case, why did you initially decide on a watchful waiting approach for the omental infarction, and why did you opt for surgery rather than radiological drainage of the omental abscess?

Dr. Khwaja: There are multiple ways of dealing with surgical complications. Once the diagnosis of omental infarction was made, a period of conservative treatment with analgesia and antibiotics was instituted based on the few cases in the published literature of omental infarction after gastric bypass. I also consulted my colleagues and used the online platform, the International Bariatric Club, to seek advice from bariatric surgeons globally. According to the sparse publications on this complication in the published literature, most patients responded to conservative treatment. That is why I initially opted for this approach for 10 days. Given that the patient was not responding to conservative treatment and then became septic, and given her history of cardiac failure, I felt intervention was imperative. Initially, I requested interventional radiology to consider draining the abscess, but they felt it would not be effective. As a result, I made the decision to do a diagnostic laparoscopy and drainage of the omental abscess, which was effective and resulted in resolution of the sepsis. I also felt that, in a patient who is immunosuppressed on steroids and with dilated cardiomyopathy, a thorough drainage of the omental abscess was of paramount importance and why I chose the laparoscopic approach.

including bleeding, anastomotic/staple line leak, dumping syndrome, marginal ulcer, gastrojejunal stricture, internal hernia, venous thromboembolism, vitamin and mineral deficiencies, port site hernia/abscess, weight regain, and a mortality rate of 0.3%.

jejunojejunostomy anastomosis with this technique, but to date I have not seen this in my practice. The important issue is the surgeon should be comfortable in his or her technique of performing the anastomoses.

Dr. Fehervari: In the second case, you changed your surgical plan. I am sure it is also something that is difficult for some patients to accept. How do you prepare your patients for something like this?

These cases illustrate that the he large amount of fatty tissuee itself can lead to significant problems and have implications on the outcomee or choice of operation.

Dr. Khwaja: I always obtain informed consent from my patients before LRYGB, as well as for LSG. For the two patients discussed in this interview, I explained and cited in my preoperative clinic letter that if we cannot perform a gastric bypass, one option would be to do a sleeve gastrectomy, after explaining in detail the benefits in terms of treating morbid obesity, effects on obesity-related comorbidities, and quality of life and possible complications.

—Haris Khwaja, MD Dr. Fehervari: Why did you elect to do a fully stapled LRYGB? Dr. Khwaja: I have performed LRYGB using many different techniques over the past 10 years, including the circular-stapled gastrojejunostomy, linear-stapled gastrojejunostomy, hand-sewn gastrojejunostomy, and a unidirectional-stapled jejunojejunostomy. After having performed all of these different techniques, I found the circular-stapled technique using the 25-mm Orvil device gives a reproducible anastomosis, is quick to perform, and, in my hands, since changing to this technique, I have not had a gastrojejunal stricture in eight years. The triple-stapled jejunojejunostomy gives a wide anastomosis and is quick and easy to perform, even in patients with a very high BMI. There are concerns of a higher incidence of intussusception of the

Dr. Fehervari: How about the intraoperative decision making? At what point should a bariatric surgeon consider converting LRYGB to LSG? Dr. Khwaja: In my opinion, if the small bowel is enveloped by adhesions after a trial dissection and if no significant progress is made to separate the small bowel, I would consider LSG. In most cases, the surgeon is aware that the patient may have a hostile abdomen by the presence of scars from previous surgeries, but in the second case, the patient had no such history except for a cesarean delivery through a Pfannenstiel incision. Of note, the abdominal CT done on the second patient showed colitis, and she is being investigated by a gastroenterologist ■ to exclude inflammatory bowel disease.

A Surgeon and His Art

Dr. Fehervari: You must have appreciated doing an LRYGB on such a patient was a very high-risk surgical option, when many surgeons would have opted for a gastric sleeve, or even a band, especially when the patient was never weaned off prednisolone.

Dr. Khwaja: Indeed, it was a high-risk surgical option, but her case had been discussed on multiple occasions in the bariatric multidisciplinary team, and it was believed that LRYGB would give her the best chance of significant weight loss and improvement in her obesity-related comorbidities, including her GERD. She was also aware of the concerns of Barrett’s esophagus after LSG and did not want that procedure. She was very motivated, adherent to the preoperative liver shrinkage diet, and fully aware of the complications of LRYGB,

“Busy London Thoroughfare,” a watercolor by Gerald Marks, MD. A joyful visit to London a decade ago found us walking the streets to visit the sites. Visual treats were everywhere and this no-named intersection with its typical London bustle was an eye-catcher.

This watercolor painted from a photo many years later captures the spirit of the moment.

7

OPINION

GENERAL SURGERY NEWS / AUGUST 2020

Achieving the ‘Holy Grail’ in Laparoscopic Cholecystectomy

By FREDERICK L. GREENE, MD

R

arely does a manuscript get published in our mainstream and peer-reviewed surgical literature that mandates reading by all general surgeons. In my view, the recent and simultaneous publication in Annals of Surgery (2020;272:3-23) and Surgical Endoscopy (2020;34:2827-2855) by the Bile Duct Injury (BDI) Task Force achieves this benchmark.

This monumental effort, launched in 2014 with the establishment of the Safe Cholecystectomy Task Force by the Society of American Gastrointestinal and Endoscopic Surgeons, led by Michael Brunt and his colleagues, reflects a multiorganizational Delphi approach to reduce the rate of BDI as a consequence of laparoscopic cholecystectomy. After working six years and poring over multiple studies, studying innumerable databases and hosting an in-person consensus conference in 2018, this group has brought its recommendations to the mainstream surgical community.

Since management of gallbladder disease is one of the most common surgical forays for both general surgical trainees and practicing general surgeons, the findings of this task force require study, reflection and embracing by all of us. With 750,000 to 1 million cholecystectomies performed yearly in the United States, the BDI rate, estimated to be between 0.15% and 0.3%, translates to 2,300 to 3,000 BDIs per year! Hopefully most of our readership have been fortunate to avoid any association with this demoralizing outcome. For others, the acute and longterm consequences for both patient and surgeon are devastating. The BDI task force has valiantly attempted to extrapolate administrative database information and literature reviews in making 18 recommendations for creating a safer environment for patients undergoing laparoscopic cholecystectomy. The authors are quick to point out that recommendations based solely on solid data may be ephemeral.

This caution, however, does not diminish the import of well-thought-out recommendations from a cadre of experts.

One of the weaknesses in considering these strategies of data collection is the problem is always bigger than you think.

We are constantly reminded of this phenomenon during the current COVID19 pandemic; there are always more infections than are extrapolated from existing testing data and hospital admissions. In considering BDI, many cases go unreported which leads to underreporting in global calculations. The task force

authors share their own frustrations in that after 30 years of performing laparoscopic cholecystectomy, there is still no national registry capturing BDI data.

Unfortunately, there never will be.

I was pleased that the task force embraced one of the strategies that I used beginning in 1990, and have been privileged to teach to surgical residents: intraoperative cholecystectomy (IOC). While

not guaranteeing a completely safe dissection and subsequent avoidance of injury, IOC is touted by the task force as being a vital strategy that will help mitigate injury.

Unfortunately, I fear that in most surgical training programs, the will and the interest to teach IOC by a preponderance of clinical surgeons is waning. It is my fervent hope that our current leaders in academic training programs will embrace the concepts of both utilization of the “critical view of safety” and IOC as promoted by the task force.

As I began, this seminal report for the mitigation of BDI should be mandatory reading for every practicing surgeon and surgical trainee. We will never fully avoid the devastation of this consequence in the performance of modern cholecystectomy. However, it is our duty to our patients and ourselves to ponder critically the outcomes over the past 30 years as we pursue the “grail” in our endeavor to ■ achieve optimal safety.

—Dr. Greene is a surgeon in Charlotte, N.C.

S

8

L I

IN THE NEWS

AUGUST 2020 / GENERAL SURGERY NEWS

Behind the Tough Decisions on Meetings During COVID-19 continued from page 1

about 200 of them,” Dr. Dietz said. “We didn’t want people who worked so hard to lose the opportunity to present their research, much of which will be obsolete by next year.”

The ASBrS decided to freeze the meeting, including the board and presidency, until next year and to hold a virtual education series that started in May; members could tune in to the sessions in real time, or view them later on the society website. More than half of the

content is eligible for continuing medical education (CME) credit.

Choosing Content The ASBrS needed only a few weeks to determine what to include in the series. “I wouldn’t say it was a no-brainer, but a lot of our content was chosen in response to what our members need,” Dr. Dietz said.

Content falls into two categories: items that probably will not be relevant a

year from now, such as scientific research, and guidance for patient care during the pandemic.

“For example, when we have to delay surgery, many surgeons put their breast cancer patients on endocrine therapy; so we held a virtual session on that topic,” Dr. Dietz said.

Dr. Dietz will not be doing her presidential address virtually, but plans to deliver it next year. She anticipates the theme she planned for the 2020

‘We didn’t want to burden our members, many of whom are taking pay cuts, or our industry partners, who need the faceto-face interaction they get in the exhibit hall. So we tried to come up with some creative solutions.’

—Jill Dietz, MD meeting—value and the patient experience—will continue to be relevant in 2021.

“I think we’ll still be reeling from the effects of COVID-19, but I also think this will remain a pertinent topic because the pandemic, in a weird way, has catapulted us toward efficiency of care.”

The technology aspect has been surprisingly easy, Dr. Dietz said. The society purchased a Zoom platform that allows up to 1,000 participants. The chat function has enabled moderators to respond quickly to comments and questions. “It’s almost seamless,” Dr. Dietz said. Glitches have been minor—a speaker forgets to unmute or a video doesn’t run.

The ASBrS was able to void its contract with the meeting site by invoking the force majeure clause, but the economic fallout has still been sizable. The society refunded all member registration fees and lost most if not all of their industry support.

“We didn’t want to burden our members, many of whom are taking pay cuts, or our industry partners, who need the face-to-face interaction they get in the exhibit hall. So we tried to come up with some creative solutions,” Dr. Dietz said.

They set up a virtual exhibit hall, promoted on the virtual meeting’s webpage, and hosted several industry-sponsored symposia. Like at the annual meeting, these sessions didn’t offer CME credit.

“But so far they’ve had pretty high attendance,” Dr. Dietz said, in an interview at the time of the ASBrS virtual meeting.

She believes this experience will forever change the ASBrS, stepping up the use of virtual resources to meet member needs. “But we also hear loudly and clearly how much everyone loves the annual meeting. If there’s a way to do it safely in 2021, we will.”

When the Meeting Is a Moving Target As early as late February, meeting directors for the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began receiving cancellations, continued on the following page

9

10

GENERAL SURGERY NEWS / AUGUST 2020

Listen to the Stories continued from page 1

likely an example of an oral tradition. Ancient generations painstakingly transmitted historical and cultural elements through the heroic tales of gods and men.

Thankfully, too, because between the blurred lines of fact and fiction we understand how they perceived life, love and loss. Thousands of years later, that emotional energy is still preserved.

By now, the newest surgery interns are on the wards and in operating rooms. To all of you, welcome. You probably feel overwhelmed and underappreciated, and if not now, then soon. The sheer number of tasks you need to complete in the course of a day will inevitably give you tunnel vision. To a degree, this is expected.

But as you become more efficient, there will be opportunities to look up and observe your surroundings. The lesson, then, is to become efficient early so as not to miss anything—your patient’s ent s nervous smile, the family’s concern, ern, a kind gesture from an attentivee nurse, the questioning looks of a new w medical student.

These are some of the human man connections that will help sustain you through ugh residency.

There is another piece of a surgical intern’s education that too often goes oes unnoticed: the stories. Beginning in yourr first academic conference, you will hear stories, dripping in nostalgia and embellished hed with time, offered up and passed around like feats of war. Try to clear ear the noise and listen to this coordinated performance as it crescendos in victory, decrescendos in disappointment, now with layers of harmony and dissonance from around the room—stories of surgery. ard By this point, I have heard es at all of my attending’s stories least three or four times. I can nearly predict the storyy based on the discussion: Being a chief and walkingg

Meetings continued from the previous page

mostly from international attendees and exhibitors but also some domestic ones.

By the first week of March, it was clear the society could not hold the meeting in early April as planned, and postponed it until August.

“So much of the value of SAGES is in the networking and fellowship. We had little interest in conducting the meeting online and no interest in canceling it,” said Sallie Matthews, the executive director of SAGES. “Based on what we knew about COVID-19 at the time, we thought August would be safe and responsible.”

Industry sponsors proved good partners, collaborating on numerous statements

the junior through the first half of a Whipple … Working two and three days straight … Standing on thick rubber mats in OR while using cyclopropane as an anesthetic …

Evacuating a hematoma bedside after thyroid surgery …

Extinguishing an OR fire during a tracheostomy … Putting a patient on cardiopulmonary bypass to repair a tracheal laceration …

I can even retell stories that were told by my mentor’s mentor. The care given to preserve these multigenerational stories is almost reverent. Be a part of that ceremony. Let yourself be transported back to that OR in 1981, where a newly minted chief struggles through a laparotomy in the middle of the night, or where a young surgeon is forced to make hard choices out of a tent in Afghanistan. The stories—big and small—are full of triumphs and failures,

The st stories—big and small—are full sma of triumphs an and failures, humor, wisdom and w creativity. creativity But they are not fantas fantastic fables.

The stories have a first and last name, and for the senior attendings, these the are the events th that shaped their the careers.

and webinars related to the pandemic.

Cleveland’s convention center and hotels were very cooperative and eager to rebook the meeting for August. “They were the best partners we could have hoped for.”

At the end of May, however, Ms. Matthews and her colleagues revised their stance on a virtual meeting, and shifted to an online platform. “It became clear that we could not safely or responsibly hold the in-person meeting in August.”

The virtual meeting will contain much of the same content as the originally scheduled—and rescheduled—meeting, with the presidential address, keynote speakers and other popular SAGES features. “We’ve made our hands-on courses virtual in a unique and exciting way that could be useful in the future, even after COVID.”

humor, wisdom and creativity. But they are not fantastic fables. The stories have a first and last name, and for the senior attendings, these are the events that shaped their careers.

To the July interns, you may be surprised to hear that surgeons are storytellers. We learn how to do it from day 1. Even more surprising is that a good portion of your first year will be consumed with how well you tell a story at the podium (think history and physical). To this end, every part of the story will be under a microscope. Each morning you will be corrected on the length, vocabulary, syntax, order and conclusion of your story, but I would argue that it is as much a skill as learning to throw a perfect square knot. Dedicate time to this skill and it will serve you well.

Even though surgery is and always will be an oral tradition, we strive to elevate surgical decision making above the level of anecdotal experience. Modern surgery exists as both an art and a science. The adoption of evidence-based medicine does not render the stories obsolete; rather, every question answered by statistics originally began as a story and they have been the impetus for change, not data. And the surgical texts that interns will pore over in just a few weeks—are they not reminiscent of Homer, seamlessly jumping between fact (evidence-based) and fiction (dogma)? Despite having undisputed authorship, each chapter is the accumulation of our collective experience, reproduced and passed down from surgeon to surgeon. And so to the new interns: Listen to the stories. After all, they are for you, to internalize and learn from.

They are your history.

“It is Surgery that, long after it has passed into obsolescence, will be remembered as the glory of Medicine. Then men shall gather in mead halls and sing of that ancient time when surgeons, like gods, walked among the human race.”

—Richard Selzer, “Letters to a Young Doctor” (1982)

■

—Dr. Halgas is a surgical resident in El Paso, Texas. His column on surgical residency appears every other month.

When the Show Just Can’t Go On A combination of timing, travel bans and COVID-19 demands drove directors of the Surgical Infection Society’s (SIS) meeting to cancel their event.

“Our meeting was very early in the pandemic, and there was no precedent for any society in terms of finding an alternative,” said Philip S. Barie, MD, MBA, the executive director of the SIS Foundation for Education and Research.

Furthermore, many SIS members are acute care surgeons, managing trauma, emergency general surgery and ICUs. The society anticipated, correctly, that its members would be fully occupied dealing with COVID-19 patients.

“Honestly, no one had the bandwidth to pivot to a virtual meeting

at that point,” said Dr. Barie, a professor of surgery and public health in medicine and an attending surgeon at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, in New York City.

The society is hopeful that it will be able to hold its traditional meeting next year, scheduled for June. But the society has the technology in place to conduct a virtual meeting, if need be.

In the meantime, SIS has invested in webinar technology and redoubled guideline-writing activities to continue to serve its membership.

“The work goes on apace,” Dr. Barie said. “We have some strong work by committees stepping up to increase our output so we can maintain the value proposition for our membership.”

■

EXTENDED HERNIA COVERAGE 2020

August 2020

Our Health Care Tragedy of the Commons Americas Hernia Society Presidential Message

By BENJAMIN K. POULOSE, MD, MPH

O Most Incisional Hernia Readmissions Occur After 30-Day Benchmark Scale of Untracked Complications Potentially Enormous; Investigators Recommend Extension of Tracking Period

By CHRISTINA FRANGOU

O

ne of every five patients who underwent an incisional hernia repair in the United States was readmitted to the hospital within a year, with most readmissions occurring after the 30-day benchmark commonly used to track health care utilization, according to a new study of hospital admissions between 2010 and 2014.

Additionally, one-fourth of readmitted patients did not return to the same hospital where they were operated on, making their complications and readmissions even harder to track in most databases.

The analysis, published in the Journal of Surgical Research, indicates many patients who are readmitted continued on page 15

More Than 30 Years of Inguinal Hernia Surgery: Have We Moved the Needle?

By GUY VOELLER, MD

H

aving been in the practice of general surgery in the same location for more than 30 years allows one a perspective on hernia surgery that may or may not be noteworthy. When I was asked by Dr. Benjamin Poulose, the president of the Americas Hernia Society, to scribble a few thoughts, I felt it might be interesting to see how things have changed (if at all) in inguinal hernia surgery over these 30 years.

It also gives me a chance to talk about the history of hernia repair, which is one of my favorite topics since we surgeons owe everything to those who went before us.

When I was training as a resident in the early 1980s, the most common autogenous repair was

the McVay, or Cooper’s ligament repair. This procedure was based on the superb work of surgeon Chester McVay and anatomist Barry Anson.

I encourage surgeons to read about this repair.

While originally described by Narath in Holland and Lotheissen, it was the paper in 1960, based on the dissection of 500 cadavers by Anson and McVay, that popularized this repair (Surg Gynecol Obstet 1960;111:707-725). Since there was tension on the repair, a relaxing incision was done in the rectus sheath to relieve it.

Another common autogenous repair at this time was what I call the North American “modification” of the Bassini repair. Modern hernia surgery was ushered in by Dr. Edoardo Bassini with his “radical cure of inguinal hernia,” a technique on which he published in 1887. This elegant operation, on which the Shouldice repair is based, reconstructs continued on page 22

riginally, this message was going to highlight the accomplishments of the Americas Hernia Society. These successes have been achieved through programs such as the newly christened Abdominal Core Health Quality Collaborative (achqc.org), “Stop the Bulge” campaign, Safe Hernia Steps, and the new WiSE (Web information, Social media, and Education) initiative that aim to make americasherniasociety.org the leading educational resource on hernia and abdominal wall disease. We look to shape the future identity of our field, breaking down traditional ways of thinking with the concept of Abdominal Core Health (abdominalcorehealth.org).

But this all changed with COVID-19.

Our practices were upended by the pandemic, and we retooled to accommodate the influx of COVID-19 patients and limit the spread of the disease. While resuming elective operations, the pandemic continues to rage with much uncertainty. As with many upheavals, the “return to normal” may never happen, yet positive meaning can emerge that leads to a better society.

With my practice on hold, I read “Proofiness: The Dark Art of Mathematical Deception,” by Charles Seife. One particular story resonated with the COVID-19 situation and health care: the “Tragedy of the Commons.” Originally described by British economist William Forester Lloyd in 1883, the “Tragedy of the Commons” describes a hypothetical situation that assumes individuals (i.e., people, corporations, health care systems) generally behave according to their own self-interest, contrary to the common good. This occurs when we are numb to the costs or negative consequences of the choice. Lloyd describes the unregulated grazing of cattle on shared land, “the commons.” Initially, the cattle owners have great benefit—large amounts of grazing land at seemingly no cost. This is sustainable for a while, until the commons can no longer continued on page 24

IN THIS ISSUE 14 Update on the AHS Quality Collaborative 16 Surgical Subspecialty Societies: Expanding Knowledge, Staying Connected 16 Quantity Over Quality: It’s Time to Up Our Game 18 The Role of Robotics in Hernia Repair

12

IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2020

Recent Top Hernia Stories in General Surgery News: A Recap Randomized Trial Pits Laparoscopy Against Robot-Assisted for Ventral Hernia Short-Term Results Suggest No Advantage With Robotic Approach, Including Length of Stay

By CHRISTINA FRANGOU

I

n the first randomized controlled trial to compare robotic ventral hernia repair and laparoscopic ventral hernia repair, no benefit was found for the robotic approach. On several key indicators, robotic ventral hernia repair failed to match outcomes associated with the laparoscopic procedure.

Compared with laparoscopic ventral hernia repair, robotic ventral hernia repair did not decrease postoperative length of stay. It doubled OR time, increased estimated costs, and did not improve short-term patient-centered outcomes.

The findings come from a trial of 124 patients randomly assigned to RVHR or LVHR at the time of the procedure.

“There does not appear to be a benefit across multiple important outcomes for ventral hernias repaired robotically,” said co-author Oscar Olavarria, MD, a surgery resident with McGovern Medical School at UTHealth, in Houston.

Over the past decade, more and more general surgeons have started using the robot, but the robot’s popularity has outpaced the scientific literature. Prior to this study, no randomized controlled

trials compared RVHR with LVHR. The trial was conducted at two hospitals in Houston between April 2018 and February 2019.

In that time, 65 patients underwent RVHR and 59 had LVHR. Patients were followed for a median of 6.4 months after surgery.

The three surgeons participating in the trial perform more than 100 hernia repairs annually.

Analysis showed the following: • Median LOS in both groups was zero days.

• Operating times for RVHR were nearly twice as long, at 141 versus 77 minutes (P<0.01).

• RVHR was associated with more enterotomies (3% vs. 0%; P=0.996).

• At one-month follow-up, patients who underwent LVHR had a greater improvement in median abdominal wall quality of life (AWQOL) scores (15 vs. 3; P=0.060).

• Health care costs were higher for RVHR, at $15,864, compared with $12,954 (P=0.004) without accounting for acquisition and service contracts of the robotic platform.

• A Bayesian analysis showed RVHR had a 78% probability of being associated with more enterotomies, and LVHR had a 66% probability of having greater improvement in early postoperative quality of life.

Dr. Olavarria said investigators believe robotic platforms will eventually replace traditional laparoscopic and open surgery.

“The key message is that it is important to rigorously evaluate innovations in surgery, including the use of robotic platforms, given that the perceived benefits may not be borne out,” he said.

[Originally published in the December 2019 issue.]

Geriatric Patients See Similar Outcomes After Lap Hernia Repair

By MONICA J. SMITH

G

eriatric patients who undergo laparoscopic ventral hernia repair tend to have more comorbidities and larger hernias than younger patients, but their outcomes and quality of life may be similar to those of younger patients, research indicates.

“Laparoscopy has been shown to improve morbidity and postoperative recovery in many patient populations. Furthermore, laparoscopic ventral hernia repair has been shown to decrease wound complications and shorten length of stay. But there’s minimal data for LVHR in the geriatric population,” said Sharbel Elhage, MD, a general surgery resident physician at Atrium Health’s Carolinas Medical Center in Charlotte, N.C. To evaluate postoperative outcomes and QOL after LVHR in geriatric patients, Dr. Elhage and his colleagues queried their institution’s prospectively enrolled database for all patients undergoing LVHR and divided them into three groups: patients under 40 years of age, patients between 40 and 64, and patients 65 and older. They used the Carolinas Comfort Scale to measure QOL, choosing a score of 2 (mild but bothersome) as indicative of nonideal QOL. Nearly 1,200 patients met the inclusion criteria. “As expected, the geriatric group had higher rates of nearly all comorbidities, including pulmonary, cardiac and diabetes; body mass index was higher in the younger population,” Dr. Elhage said.

The older population also had larger defects, but their number of prior recurrences was similar to that of the younger cohorts.

The hernia-specific outcomes were similar among the three cohorts, with the exception of seroma requiring intervention, which was slightly higher in the geriatric group. Recurrence, too, was similar among all groups, at 5.7% with a mean followup of 44 months.

The team assessed pain, mesh sensation, activity limitation and overall QOL at two weeks, one month, six months and 12 months. They found mesh sensation similar among the three groups.

[Originally published in the May 2020 issue.]

Primary Fascial Closure With Lap Hernia Repair Supported by Study

By CHRISTINA FRANGOU

P

atients who have a primary fascial closure before mesh placement during laparoscopic ventral hernia repair enjoy better long-term quality of life than those who undergo a standard bridged repair, according to results from a multicenter, randomized controlled trial.

“This study provides the high-quality evidence that primary fascial closure significantly improves patients’ quality of life and function,” said lead author Karla Bernardi, MD, a researcher with McGovern Medical School at UTHealth, in Houston.

The investigators now recommend patients with hernia defects greater than 3 cm do not have a bridged repair.

“Among patients undergoing elective LVHR, the fascial defect should be closed,” Dr. Bernardi said.

Between 2015 and 2017, 129 patients were randomized to undergo PFC or a bridged repair during an elective LVHR at four institutions in the United States. All patients had hernia defects between 3 and 12 cm on

CT; most were obese, had one or more comorbid conditions, and had prior abdominal surgery.

Before surgery, all patients completed the modified Activity Assessment Scale (mAAS), a validated hernia-specific, QOL survey that measures pain, function, cosmesis and satisfaction. Scores range between 1 (very poor) and 100 (perfect).

During each operation, just before mesh placement, the surgeon called the randomization office to determine the next step of the procedure, based on a computer-generated variable block randomization.

For patients in the PFC arm, the fascia was closed using a percutaneous technique. Small stab incisions were made along the long axis of the hernia defect, and 0-polydioxanone sutures were placed every 1 cm.

For both groups, the mesh was then secured with four 0-polydioxanone positioning sutures and tacked with a double crown of permanent tacks.

Of the 129 patients enrolled in the trial, 107 (83%) completed a QOL survey two years after surgery.

Results showed the following:

• Patients in both arms reported significantly improved QOL after repair, but the PFC group experienced a 12-point greater improvement (41.3±31.5 vs.

29.7±28.7; P=0.047).

• Patients who had PFC experienced greater improvements in their ability to carry out physical activities than those in the bridged repair arm, based on subsets of the mAAS scores.

• There was no significant difference in chronic pain or pain scores after treatment based on mAAS scores.

• There was no difference in clinical outcomes with PFC compared with bridged repair.

• Operations with PFC took, on average, 13 minutes longer.

Disclosures: Dr. Bernardi’s co-authors Dr. J.S. Roth received associate research funding from Davol Inc. and Intuitive Surgical, and Dr. S. Tsuda received compensation from Allergan. This funding was not used for this project.

[Originally published in the February 2020 issue.]

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14

OPINION

GENERAL SURGERY NEWS / AUGUST 2020

Transforming Care for Hernia Patients Through Collaboration An Update on the AHS Quality Collaborative

By MICHAEL J. ROSEN, MD

O

n behalf of the entire Americas Hernia Society Quality Collaborative, I’d like to share with you some of our key accomplishments and updates on how we are transforming our knowledge of hernia repair and improving patients’ outcomes through the principles of collaborative learning. All of our stakeholders, including our patients, surgeons, FDA colleagues and Foundation partners share our vision and continue to invest their time and resources in support of this national effort to advance the quality of hernia repair.

What we have accomplished since 2013 is truly inspiring, and I hope many others will join this effort as we are really just getting started.

The quality collaborative, or AHSQC, continues to grow, with increasing numbers of surgeon participants and procedures captured. Through collaboration among our stakeholders, the AHSQC uses continuous quality improvement methods and a systematic, userfriendly, patient-centric approach to streamline realworld data collection from hernia and abdominal wall procedures. Our process allows for systematic collection of clinically relevant information, including pre-, intra- and postoperative details during the routine care of patients that can be critically analyzed to identify areas where patient outcomes may be enhanced. We share this information widely via multiple avenues and across a range of platforms to maximize our direct impact on hernia patient care.

We have expanded our focus to represent the complexity of diseases of the abdominal wall and treatment of abdominal core health and now track outcomes of primary, incisional, parastomal, inguinal and rectus diastasis repairs, management of chronic groin pain, and abdominal wall oncology. These operations include routine hernia repairs up to some of the most complex reconstructive challenges surgeons face. Recognizing the magnitude of approaches to hernia repair, we collect granular information on key surgical techniques, and approaches including open, laparoscopic and robotic repairs. These data will enable us to understand the specific merits of all of these options and use them in the most appropriate patients to optimize results. Our ranks now include over 400 surgeons across the United States who collectively donate thousands of hours to the AHSQC each year. These surgeons represent a diverse practice group that includes solo private practice surgeons to large group practices in academic institutions. With a nearly even representation of private practice and academic surgeons, we continue to obtain real-world outcomes that are relevant to all stakeholders. Thanks to these dedicated surgeons, the AHSQC registry surpassed 60,000 patients this year and we have seen linear growth since our inception.

With patients at the core of the AHSQC’s mission, we continually strive to understand and improve their experiences—before, during and after surgery.

This year the AHSQC took several opportunities to team up with health care providers in other disciplines, extending our collaborative reach focusing on abdominal core health. Surgeons with the AHSQC forged

dynamic interrelationships with colleagues specializing in pain management, anesthesiology, physical therapy, occupational therapy, nursing and rehabilitation services, and jointly created several interactive and engaging tools for patients and their care providers. These innovations include our AHSQC mobile app, Abdominal Core Surgery Patient and Physical Therapy Rehabilitation Guides, and informational handouts to educate patients on the risk of opioids and offer alternative pain management options following hernia surgery. All of these resources are available for free download on our website (www.ahsqc.org). We recently launched our free AHSQC app, which is available in iOS and Android formats. The app is designed to improve the outcomes of patients undergoing abdominal and hernia surgery, offering recommendations for self-directed prehabilitation efforts and physical therapy guidance during their postoperative stay and at subsequent two-week intervals. These efforts focus on core strength and early activity aimed at reducing complications and improving outcomes.

Many registries focus solely on data collection, but at the AHSQC, we are actively engaged in the operational arm of quality improvement and improving outcomes through collaborative learning.

With the opioid epidemic continuing to plague the United States, the AHSQC is committed to using our collaborative network to identify actionable measures to confront this national crisis. Under the guidance of our opioid reduction task force lead, Dr. Micki Reinhorn, we have created a patient-friendly document with guidelines and alternative approaches to treating early postoperative pain after hernia surgery (www.ahsqc.org/patients/opioid-reduction-initiative). Two key aspects of this initiative involve surgeons limiting their postoperative opioid prescription to no or up to 10 tablets following inguinal and umbilical hernia surgery, and incorporating a multimodal, nonopioid pain management strategy as a firstline approach with opioids used as a “rescue” medication.

As a collaborative, we have already seen substantial reductions in narcotic prescriptions. We know that providing these tools to patients can help play a tremendous role in enhancing surgical outcomes. Patients who are engaged and educated ultimately become more informed decision makers, who we hope feel more empowered to talk with their care providers and take a more active role in the management of their individual care.

The AHSQC continues to be a preeminent source of high-quality, comprehensive and clinically relevant information on hernia surgery. We continue to relentlessly search for data-driven answers to questions about our treatment of hernia patients in order to optimize outcomes. The bibliography of peer-reviewed publications using AHSQC data analyses has now reached 45, with 19 new articles published in high-impact journals over the past 18 months. A highlight of these works includes our first utilization of the registry to perform postmarketing surveillance by engaging all stakeholders. Additionally, our collaborative has successfully advanced high-quality research in the field of hernia surgery by focusing our efforts on conducting

embedded randomized studies within the AHSQC. These efforts will likely reshape the practice of hernia surgery through evidence-based medicine.

Many registries focus solely on data collection, but at the AHSQC, we are actively engaged in the operational arm of quality improvement and improving outcomes through collaborative learning. Building on the success of 2018’s inaugural Quality Improvement Summit, we closed 2019 by hosting our second QI Summit, “A Collaborative Approach to Improving the Hernia Patient Experience—Spotlight on Optimizing Umbilical Hernia Repair,” in December. The meeting facilitated networking with peers and collaborative learning during interactive sessions. Attendees discussed approaches to continually improve techniques with high-performing colleagues and considered best practice suggestions to implement upon returning home. I’m excited to share that plans for the next QI Summit are already underway.

Recognizing the critical role of regulating medical devices in the hernia space, we continue to forge relationships at the federal level. The AHSQC helps direct the FDA’s MDEpiNet Abdominal Core Health Coordinated Registry Network, which has made significant progress in developing unique methods to enhance postmarketing surveillance. MDEpiNet is a global public‒private partnership that brings together leadership, expertise and resources from health care professionals, industry, patient groups, payors, academia and government to advance a national patient-centered medical device evaluation and surveillance system. Through these efforts, we are confident we will be able to build a better system to offer our patients the best possible outcomes in a safe and innovative environment. The AHSQC continues to be recognized by the Centers for Medicare & Medicaid Services as a merit-based incentive payment system (or MIPS) qualified clinical data registry and by the American Board of Surgery to fulfill Part 4 of the Maintenance of Certification program.

The AHSQC has seen tremendous growth in service to our community of patients, surgeons, care teams and partners. While celebrating our past successes and overcoming challenges, we recognize that our future depends on new ways of thinking about focusing on health and not dwelling on disease. The concept of abdominal core health leads this innovation by exploring the relationships between the abdominal wall, diaphragm, pelvic floor and lower back. Critical to this effort will be gathering high-quality data in hernia disease and beyond.

To this end, the AHSQC has evolved into a more comprehensive organization incorporating the multidisciplinary teamwork that is inherent to caring for patients with abdominal core problems, and has renamed itself the Abdominal Core Health Quality Collaborative— ACHQC. With this new distinction, we believe we will increase our collaborative network and improve outcomes further. We enter the new decade energized and fully committed to our mission as an exciting, refreshed ■ “QC.” We welcome you to join us!

—Dr. Rosen is the medical director of the ACHQC and director of the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio.

Disclosure: Dr. Rosen reported salary support for his role as the medical director of the ACHQC. His institution has received grant support for principal investigator roles in trials with Intuitive and Pacira.

15

AUGUST 2020 / GENERAL SURGERY NEWS

Incisional Hernia Readmission continued from page 11

with complications following incisional hernia repair are overlooked, leading to consistent underreporting of complications.

“Patients, and some clinicians, may not be aware of how prevalent readmissions are after incisional hernia repair and that most readmissions are related to postoperative complications,” said study author Arturo J. Rios-Diaz, a fourth-year general surgery resident at Thomas Jefferson University, in Philadelphia.

Many of the readmitted patients required substantial treatment. Onethird of them underwent a subsequent major procedure during their return stay and 4.1% experienced a recurrence requiring an inpatient revision of their repair.

The study confirmed what some surgeons and patients have long suspected: Many complications and events related to quality of care in hernia, especially ventral hernia, occur well beyond the 30-day postoperative time point, said Benjamin Poulose, MD, a professor of surgery at the Ohio State University, in Columbus. This is especially important given that surgeons implant meshes in patients, expecting them to stay in place for years.

“This should be another wake-up call—not only to hernia surgeons, but also to hospitals, payors and those funding quality improvement and research efforts,” Dr. Poulose said.

With more than 350,000 incisional hernia repairs performed in the United States annually, the scale of overlooked complications is potentially enormous, with tens of thousands of patients requiring readmission for infections more than 30 days after surgery.

There is too little understanding in the field about why, how and in whom complications are occurring long term, and these uncertainties are driving massive legal actions in hernia repair, Dr. Poulose said. “We, as surgeons, can no longer just accept the status quo.”

Surgeons should follow their patients long term and develop targeted strategies to reduce complications, including appropriate patient selection, prehabilitation when needed, and good surgical judgment during the performance of the procedure, he said.

The researchers used the Nationwide Readmissions Database to study readmission rates of patients who underwent elective incisional hernia repair between 2010 and 2014. In that period, 15,935 patients underwent incisional hernia repair and 19.35% were readmitted within one year. Only 39.3% of readmissions happened in the first 30 days after surgery.

Complications were the leading cause of readmission, accounting for 50%, with half of them due to infectious complications. Of all patients readmitted for infection, 91.8% were initially discharged within a record to indicate infection. Readmission for bowel obstruction was found in 5% of patients, which is higher than previously reported rates and may be explained by the broad definition used by investigators.

Estimated Costs of Readmission For Incisional Hernia Annual cost of unplanned readmissions:

$90+ million per year Predicted mean difference in cumulative costs:

$12,189.70 higher for patients readmitted within one year Predicted mean difference in length of stay:

6.1 days longer for patients readmitted within one year

Reoperations were performed in 35% of readmitted patients and 5% had revisions to their repair.

The results highlight the need for national policies that require physicians to follow patients and collect data beyond 30 days, the investigators said.

Most data on health care utilization after incisional hernia repair are only carried out to 30 days after surgery and are not nationally representative.

Dr. Rios-Diaz and his colleagues believe the readmission benchmark for incisional hernia repair should be continued on page 23

In complex hernia repair, patient risk factors and postoperative wound complications can contribute to the peril of hernia recurrence

In a recent retrospective evaluation of biologic meshes,

S T R A T T I C E™ R T M,

A 100% BIOLOGIC MESH, IS A DURABLE SOLUTION for abdominal wall reconstruction based on the long-term outcomes of low hernia recurrence rates across multiple published clinical studies1-5

91.7%

of patients were

RECURRENCE-FREE AT

7 YEARS post-op1,*

*Includes porcine and bovine acellular dermal matrices (ADMs) (n = 157) 5 .

Bridged repair and human ADM were excluded from the study group.

TO LEARN MORE ABOUT STRATTICE™ RTM, SPEAK TO YOUR ALLERGAN REPRESENTATIVE INDICATIONS STRATTICE™ Reconstructive Tissue Matrix (RTM), STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are intended for use as soft tissue patches to reinforce soft tissue where weakness exists and for the surgical repair of damaged or ruptured soft tissue membranes. Indications for use of these products include the repair of hernias and/or body wall defects which require the use of reinforcing or bridging material to obtain the desired surgical outcome. STRATTICE™ RTM Laparoscopic is indicated for such uses in open or laparoscopic procedures.

These products are supplied sterile and are intended for single patient one-time use only.

IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS These products should not be used in patients with a known sensitivity to porcine material and/or Polysorbate 20.

WARNINGS Do not resterilize. Discard all open and unused portions of these devices. Do not use if the package is opened or damaged. Do not use if seal is broken or compromised. After use, handle and dispose of all unused product and packaging in accordance with accepted medical practice and applicable local, state, and federal laws and regulations.

Do not reuse once the surgical mesh has been removed from the packaging and/or is in contact with a patient.

This increases risk of patient-to-patient contamination and subsequent infection.

For STRATTICE™ RTM Extra Thick, do not use if the temperature monitoring device does not display “OK.” PRECAUTIONS Discard these products if mishandling has caused possible damage or contamination, or the products are past their expiration date. Ensure these products are placed in a sterile basin and covered with room temperature sterile saline or room temperature sterile lactated Ringer’s solution for a minimum of 2 minutes prior to implantation in the body. Place these products in maximum possible contact with healthy, well-vascularized tissue to promote cell ingrowth and tissue remodeling. These products should be hydrated and moist when the package is opened. If the surgical mesh is dry, do not use.

Certain considerations should be used when performing surgical procedures using a surgical mesh product. Consider the risk/ benefit balance of use in patients with significant co-morbidities; including but not limited to, obesity, smoking, diabetes, immunosuppression, malnourishment, poor tissue oxygenation (such as COPD), and pre- or post-operative radiation.

Bioburden-reducing techniques should be utilized in significantly contaminated or infected cases to minimize

contamination levels at the surgical site, including, but not limited to, appropriate drainage, debridement, negative pressure therapy, and/or antimicrobial therapy prior and in addition to implantation of the surgical mesh. In large abdominal wall defect cases where midline fascial closure cannot be obtained, with or without separation of components techniques, utilization of the surgical mesh in a bridged fashion is associated with a higher risk of hernia recurrence than when used to reinforce fascial closure.

For STRATTICE™ RTM Perforated, if a tissue punch-out piece is visible, remove using aseptic technique before implantation.

For STRATTICE™ RTM Laparoscopic, refrain from using excessive force if inserting the mesh through the trocar.

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References: 1. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350. 2. Golla D, Russo CC. Outcomes following placement of non-cross-linked porcine-derived acellular dermal matrix in complex ventral hernia repair. Int Surg. 2014;99(3):235-240. 3. Liang MK, Berger RL, Nguyen MT, Hicks SC, Li LT, Leong M. Outcomes with porcine acellular dermal matrix versus synthetic mesh and suture in complicated open ventral hernia repair. Surg Infect (Larchmt). 2014;15(5):506-512. 4. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg. 2013;217(6):999-1009. 5. Richmond B, Ubert A, Judhan R, et al. Component separation with porcine acellular dermal reinforcement is superior to traditional bridged mesh repairs in the open repair of significant midline ventral hernia defects. Am Surg. 2014;80(8):725-731.

Allergan® and its design are trademarks of Allergan, Inc. STRATTICE™ and its design are trademarks of LifeCell Corporation, an Allergan affiliate. © 2020 Allergan. All rights reserved. STM134734 03/20

16

OPINION

GENERAL SURGERY NEWS / AUGUST 2020

Surgical Subspecialty Societies: Expanding Knowledge, Staying Connected

By REBECCA PETERSEN, MD, MSc

his issue of General Surgery News is dedicated to a condition in which the chief responsibility for diagnosis and management rests squarely with the general surgeon, namely hernias. Yet, in the broader discipline of general surgery, several highly functioning and productive subspecialty professional societies have developed: the European Hernia Society, Americas Hernia Society (AHS), Americas Hernia Society Quality Collaborative, and American Foregut Society (AFS). These societies coexist with another society that many might also consider a subspecialty society, the Society of Gastrointestinal and Endoscopic Surgeons (SAGES), which also coexists with larger professional societies such as the American College of Surgeons, Society of University Surgeons, and American Surgical Association.

For a surgeon in a busy practice, the temptations may be to ask: 1) are there too many societies, and 2) how am I to keep up with the information generated

T

by these societies? In turn, the societies must ponder the financial realities of maintaining membership to support their missions, while realizing that an inherent competition exists for funding resources and membership among practicing surgeons.

This is not a new problem, but rather it represents the natural progression of the development of knowledge, technical expertise and need for specialized communication. The evolution of surgical societies reflects these advancements over time (Figure). There was an era in which there was no such thing as a general surgeon; there was only a surgeon who did every and any procedure ranging from leg amputations to craniotomies.

Over time, the existing specialties of general, neuro, trauma, orthopedic, urologic, oncologic, cardiothoracic, vascular and plastic surgery have evolved out of advances in knowledge and technology, and the recognition that focusing practice leads to improvement in outcomes.

Within our own specialty of general surgery, hernia subspecialization simply reflects the inevitability of progress.

So, back to the future. How do we continue growth in an era when surgeons are

being asked to do more with less resources and the overall health care system has hit its financial limits? The answers lie with the technological advances in communications in our times. The fundamental concept of a professional society is to foster communication. In an era when the only means of communication was mail or telephone, national meetings were the only way to allow for focused, inclusive discussion and construction of collaborative knowledge in medical specialties.

Over time, this evolved into a platform for networking and socializing, and based on the locations of the meetings, recreation as well. Equally importantly, larger societies have come to rely on national meetings as a critical source of revenue.

However, the rubric of a large national meeting as the chief means of communication has been fading for some time.

Well before 2020, the availability of information on the internet and the subspecialization in all areas of medicine have led to declining attendance at traditional national meetings. Surveys of younger physicians demonstrate that most would prefer to receive their continuing medical education on their own terms via electronic means, rather than attending conferences.1

The response has been to try to repurpose the meetings to attract a broad base of attendees, but in many cases the ability to provide a forum for highly specialized discussion has been lost. The counterresponse has been the rise of subspecialty societies such as the AHS and the AFS. Enter the coronavirus. Insert whatever metaphor you want about lemons and lemonade or silver linings, the changes in communication generated by the COVID-19 pandemic will echo for years to come. Live internet-based communication is here to stay and it needs to be embraced instead of shunned. Dissemination of information will be delivered virtually at this year’s SAGES Scientific Sessions despite the largest public health disaster in over 100 years, largely through the willingness of the societies’ leadership to embrace an internet-based strategy for communication. This is only the beginning and the opportunities are vast.

Cross-collaboration should be established and encouraged between varying societies. Whereas highly specialized societies such as the AHS and AFS can provide the thought leadership for specific topics, larger societies have the resources to produce content and the

Quantity Over Quality in Hernia Data: It’s Time to Up Our Game

By AJITA S. PRABHU, MD

A

current search of the term “hernia” in the PubMed database reveals 94,144 articles, the first of which was published in 1785. Yet curiously, operations for hernia repair across the United States— and, indeed, around the world—remain woefully inconsistent not only in their technical approach, but also in expected outcomes. In an environment where reducing variability in the delivery of care is the linchpin to securing reproducible and quality health care outcomes, our vast literature has yet to produce the answers we seek. How is it that we have published so much and at the same time learned so little about this ever-present and common disease?

Without question, hernia disease is complicated by its own inherent variability, which is further compounded by the specific clinical scenario of each patient. Remarkably, the first challenge occurs here, from the utterance of the word “hernia,” with our failure to have standardized even the classification of the disease. Beyond that, our collective bibliography is rife with case series and

retrospective reviews of varying quality, establishing our academic prominence and also singularly unable to answer the questions we need answered the most.

To be clear, there is plenty of value to publications at all levels of evidence.

Many studies do contribute to our overall knowledge base. Still, it is high time that we address the elephant in the room: There is an urgent need to establish high levels of evidence in hernia surgery in order to best serve our patients.

If we are honest about it, for the most part, we have gamely celebrated the metaphorical side dishes while casually overlooking the conspicuous absence of the entrée. Where are the randomized controlled trials (RCTs)?

To better put the discussion in context, we could compare hernia disease to oncologic disease. We would never simply throw our hands in the air and say cancer is too complicated, so we will just settle for what little knowledge we have. Furthermore, we would likely avoid treating surgical oncologic disease based on the hearty recommendations of a social media group. Why are we so quick to be complacent in hernia surgery? While some would argue that hernias are benign disease and do not merit such

consideration as cancer, our hernia recurrence rates remain unacceptably high and mesh-related complications can deliver a devastating blow to our patients, resulting in additional surgery approximately 5% of the time (JAMA 2016;316[15]:1575-1582).

Perhaps “benign” is a poor descriptor.

Why are we so reluctant to accept that enlightenment will only come one difficult step at a time?

The relative scarcity of well-designed RCTs in hernia surgery is likely multifactorial. Commonly cited impediments to execution include cost, burden of execution and surgeon time commitment. Despite these obstacles, there are certainly avenues to overcome them, including registry-based trials (J Surg Res 2020;255:428-435). Such studies leverage observational registries by thoughtful design of pragmatic studies, tailored to fit into the standard workflow of participating surgeons and minimizing excessive burdens in terms of time and effort. Additionally, detractors are often critical of RCTs due to their well-known limitations:

They are narrow in their inclusion criteria and can fail to provide generalizable conclusions, and they are not usually powered to detect low-frequency, catastrophic complications. Often, these limitations are used as justification for rejecting these studies while attempting to establish a moral high ground. Through our impetuous and myopic lens, we have surrendered our academic vigor in favor of comfortable routine. In reality, a well-designed RCT is meant to definitively answer one focused question and to contribute one piece of useful evidence, in this case to our overall understanding of hernia disease. Why are we so reluctant to accept that enlightenment will only come one difficult step at a time, and with a sustained campaign to build on our existing knowledge?

It would be misleading to imply that RCTs are the sole remedy or that most surgeons, regardless of their setting, should (or could) conduct RCTs. Community-based and private practice surgeons often lack the resources (including infrastructure, time and/or desire) to participate in or run these types of trials. Still, observational registries can augment our understanding by providing the granular detail missing from retrospective chart reviews, and additionally by facilitating surveillance of the devices

17

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Figure. Timeline of founding dates for selected surgical societies.

1880 American Surgical Ass

1880

ability to disseminate knowledge to a broader audience. Moreover, the logistics of meeting in person are moot, and there is a clear appetite for internet-based content that can be stored and viewed on demand, and the ability to generate and share revenue from internet content is well established. The time has come for the various professional societies to truly coexist.

This is not a requiem for the traditional scientific session meeting. There will always be value in genuine face-toface interaction. However, it is possible that the agenda and purpose of an annual meeting may change, hopefully for the better. So, to answer the dilemma facing the practicing general surgeon regarding the various professional societies: 1) yes, subspecialized societies are necessary and reflect the inevitable expansion of knowledge, and 2) if done correctly, keeping up with the information will be easier in the future rather than harder.

■

ation

AUGUST 2020 / GENERAL SURGERY NEWS

1887 American Orthopedi

1900

Reference

1902 American Urologi

1. Acad Med. 2017;92(9):1335-1345. doi: 10.1097/ACM.0000000000001624

1920

—Dr. Petersen is an associate professor of surgery at the University of Washington Medical Center, in Seattle.

1912 American Colle

1917 American Ass Surgery

The Americas Hernia Society is excited to announce that it is shifting to a virtual platform for the 2020 Annual Meeting.

1931 American So 1931 American A Surgeons

1940

1947 Societ

Dates: September 25-26, 2020

1

2020

For more detailed information, please visit www.americasherniasociety.org.

198

2000

The meeting promises to be an innovative leap forward in education and networking. Live portions of the meeting will be held Sept. 25-26. In addition, asynchronous sessions will be offered to tailor your meeting experience at your convenience.

Details regarding this exciting format will be forthcoming.

1957 Soci Trac

1980

—Dr. Prabhu is associate professor of surgery, Cleveland Clinic Foundation, in Ohio.

1940 Society

1960

upon which the field of hernia surgery has come to heavily depend. Arguably, we should reasonably expect that some part of our great responsibility includes registry participation at a minimum, regardless of our practice setting.

We need to begin by acknowledging that we truly know very little about the treatment of hernias. Furthermore, we need to acknowledge the legitimacy of peer-reviewed publication, and to critically appraise the idea that crowdsourcing anecdotes through social media groups can result in meaningful change or reasonable surgical care of patients. Beyond that, we need to hold ourselves accountable for contributing to our profession. This is particularly important given that we benefit (indeed, make our livelihood) from the suffering of others. Finally, our contributions should be meaningful. RCTs can and should be the cornerstone of our understanding of hernia disease, bolstered by registry-based prospective and retrospective studies. Lower evidence studies should assume their rightful place as contributors, not dogma. We can, and should, ■ do better. Our patients expect it.

1938 Society o 1938 American of Traum

18

OPINION

GENERAL SURGERY NEWS / AUGUST 2020

The Role of Robotics in Hernia Repair

By JEREMY WARREN, MD, FACS

P

erhaps no surgical technology generates as much fervent support or vehement criticism as the robot. While few would dispute the technical advantages of articulating instruments and 3D visualization, many have questioned the widespread adoption without clear evidence supporting its use, particularly in the face of significant initial cost. Adoption of robotic ventral and inguinal hernia repair (rVHR and rIHR) should be evaluated critically in four major areas: • Is it beneficial to the patient?

• Are there advantages to the surgeon regarding learning curve or ergonomics?

• What is the cost?

• How do we train surgeons on new technology and novel techniques?

This brief overview will examine the benefits, limitations and controversies surrounding robotics in hernia repair.

Clinical Outcomes in rIHR Current literature on rIHR is limited, but indicates comparable risk for complications, recurrence and patient satisfaction to laparoscopic IHR (LIHR).

There is a robust body of literature supporting LIHR, demonstrating reduced acute postoperative pain and incidence of chronic postoperative inguinal pain, and similar rates of complications and recurrence to traditional open repair (Hernia 2018;22[1]:1-165). Robotic IHR emulates LIHR with some minor variations in technique, notably a transition to predominantly transabdominal preperitoneal (TAPP) repair from a predominantly totally extraperitoneal (TEP) approach for LIHR. Additionally, few surgeons performing rIHR use tack or staple fixation and use sutures to close the peritoneal flap, which may reduce postoperative pain.

Early results of a multicenter prospective trial of more than 500 patients comparing open IHR, LIHR and rIHR favor LIHR and rIHR over open IHR, with similar outcomes between the two.

Fewer patients reported taking opioid analgesia in the rIHR group compared with LIHR, although the mean number of pills was no different (Hernia 2020;362:1561-1565). In the RIVAL trial, a prospective randomized multicenter trial of laparoscopic versus robotic TAPP IHR, no difference was seen in complications, readmissions, pain, physical activity or cosmesis (JAMA Surg 2020;155[5]:380-387). The excellent clinical outcomes of LIHR will make

it difficult to prove the superiority of rIHR, and these should be considered equivalent at this point.

Clinical Outcomes of rVHR There are several variations of rVHR that must be considered.

Robotic Intraperitoneal Only of Mesh Robotic IPOM is a modification of standard laparoscopic VHR, utilizing a transabdominal approach to bridge or reinforce the hernia with intraperitoneal mesh. This technique is the simplest and the most commonly performed rVHR, and has the distinct advantage of reliable closure of the hernia defect. Reinforcement of a closed defect rather than bridging has mechanical advantages, particularly for larger defects, that reduce the risk for mesh eventration and recurrence, and may decrease the rate of seroma (Hernia 2017;20:893-895; Surg Endosc 2019;33[10]:3069-3139). Additionally, most surgeons performing rIPOM fixate the mesh with intracorporeal sutures rather than tacks or transfascial sutures.

Advocates report less postoperative pain with this approach, although this has not been clearly demonstrated in the literature.

Robotic TAPP Repair While relatively uncommon, complications of intraperitoneal mesh can be devastating. Further, intraperitoneal mesh may complicate subsequent abdominal operations, which are required in as many as 25% of patients after hernia repair (J Am Coll Surg 2011;212[4]:496502). This has led many to prefer extraperitoneal mesh placement. Robotic TAPP utilizes the preperitoneal space for mesh reinforcement, mitigating these risks associated with IPOM. Reports of rTAPP compare favorably to LVHR and rIPOM (Hernia 2020 May 5. Epub ahead of print]; Hernia 2019;23[5]:957967). There is little risk for damage to the abdominal wall with this procedure, and if the peritoneal flap integrity cannot be maintained, conversion to IPOM is straightforward.

Robotic Retromuscular Repair Probably the most innovative application of rVHR is the reconstruction of the abdominal wall. Widely considered the gold standard for open repair, retromuscular (RM) VHR provides rectus abdominis myofascial release to allow defect closure and creates an extraperitoneal plane for mesh placement. The addition of a transversus abdominis release (TAR) further mobilizes the abdominal wall for closure of larger hernia defects and wider mesh reinforcement.

A transabdominal approach can be used to access the RM space, most often with the addition of TAR. This approach reduces the length of stay compared with open and laparoscopic IPOM, and may reduce surgical site infections (Ann Surg 2018;267:210-217; Surg Endosc 2017;31[1]:324-332). However, its application should be limited to patients with larger defects that would require TAR, if performed open, to avoid unnecessary myofascial release.

Recently, the extended-view totally extraperitoneal (eTEP) repair has garnered significant attention, and is our preferred approach for most rVHR. This technique allows a more tailored approach by first releasing the rectus sheath alone, with additional rTAR only if needed. eTEP has allowed us to convert from traditional open RM VHR or LVHR with an inpatient stay of one to three days to an outpatient procedure in most cases, a finding reported by other authors as well (Hernia 2018;22[5]:837847; Surg Endosc 2020;23:957-1007).

more surgeons to transition from open to minimally invasive IHR.

Cost of Robotic Hernia Repair Disparate data exist on the costs associated with robotic compared with open or laparoscopic repairs (JAMA Surg 2020;155[5]:380-387; J Robot Surg 2016;10[3]:239-244). The initial expense of the robot and associated maintenance contracts are significant. Patient charges are likely higher after robotic repair (J Am Coll Surg 2020;231[1]:61-72). However, these results are not necessarily generalizable. Direct hospital costs can vary depending on vendor contracts and individual surgeon supply utilization. Indirect costs vary according to billing structure and payor contracts. Potential cost savings of shorter length of stay should offset the cost for rVHR. Finally, quantifying the potential benefit of earlier return to work is challenging. At this point, robotic surgery cannot be judged solely on the basis of cost.

Training Surgeon Advantages of rIHR Proponents often cite ergonomic benefits of the robot. Musculoskeletal injury is a known hazard of laparoscopic surgery (J Am Coll Surg 2010;210[3]:306-313).

The ability to sit down and adjust the robotic console components is appealing.

However, there remains a risk for injury.

In the RIVAL trial, surgeon ergonomics were not significantly different between LIHR and rIHR, both demonstrating a high risk for musculoskeletal injury (JAMA Surg 2020;155[5]:380-387).

A study of ergonomics in robotic gynecologic surgery reported similar findings (J Minim Invasive Gynecol 2013;20[5]:648 -655). Greater awareness and education are needed to mitigate this risk and take advantage of the potential ergonomic benefits of the robotic platform.

The learning curve of complex laparoscopy is significant, requiring up to 200 laparoscopic IHRs to reach proficiency, which contributes to its relatively limited adoption (Hernia 2018;22[1]:1165). The robot may shorten the learning curve of minimally invasive IHR (Surg Endosc 2018;32[12]:4850-4859).

Robotic simulation very closely approximates the reality of operating on the system. Additionally, through novel training and mentorship paradigms, most notably the International Hernia Collaboration (IHC) and Robotic Surgery Collaboration (RSC), there is a wealth of videobased technical instruction and almost real-time peer review available to new surgeons adopting rIHR or rVHR. It remains to be seen whether this will lead

Residency or fellowship programs are the best model for training in novel surgical techniques, but this excludes practicing surgeons. For these surgeons, training is done primarily through industry-sponsored programs, postgraduate courses in conjunction with society meetings, live proctoring, selfguided learning, and virtual mentorship via groups such as the IHC or RSC. While this is adequate for many surgeons, it may not be for all, and there is no way to accurately assess proficiency of the learner. There are legitimate concerns from high-volume hernia referral centers, including our own, that some adopting these techniques may not appreciate the subtleties of the RM and TAR anatomy, resulting in disruption of the semilunar line and complex lateral hernias (Hernia 2020;24[2]:333-340). It is imperative that we continue to explore innovative options for mentoring surgeons in novel techniques.

Interest in robotic hernia repair will undoubtedly continue, and adoption almost certainly will increase. While there will continue to be critics of robotic hernia repair, the ideal application of this innovative and enabling technology will become clearer as data emerge from ongoing clinical trials.

■ —Dr. Warren is an associate professor of surgery at the University of South Carolina School of Medicine in Greenville.

Disclosure: Dr. Warren serves as an instructor and speaker for and receives honoraria from Intuitive.

19

The Art of Herniology: 2020, Part 2 Guidelines for hernia repair are valuable.

Well-developed guidelines are excellent summaries of available data and expert opinion. Society-based guidelines tend to be the best, especially if developed in a rigorous and transparent way. You’ve got to be careful about the source of the guidelines, intent and conflicts of interest of the authors. We should also keep in mind that guidelines are guidelines—they can’t be applied to all situations and all surgeons.

BENJAMIN POULOSE, MD: AGREE

or this year’s second installment of “The Art of Herniology,” we address hernia surgery and COVID-19 as well as other topics: Should national conferences completely move to virtual meetings?

How valuable are guidelines for hernia repair?

Following our experience with the COVID-19 pandemic, do we need a new definition of “elective surgery”? Do biosynthetic meshes hold the key to the future of hernia repair? And should surgeons be held accountable for the costs incurred by their operations?

I would like to thank all of the contributors for their time and effort. Their hard work and time make this a compelling installment, in which no statements achieve even close to a consensus. Don’t forget to check out “Gut Reaction” on page 20 for some quick, candid thoughts from these contributors.

Feel free to email me at colleen@ cmhadvisors.com with any ideas for debate te ry. in hernia and other areas of general surgery.

Thanks for reading!

F

—Colleen Hutchinson Colleen Hutchinson is a medical communications consultant at CMH Media, based in Philadelphia.

She can be reached at colleen@cmhadvisors.com.

PARTICIPANTS Aurora Pryor, MD, MBA Professor of surgery; chief of the Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery; and vice chair of clinical affairs at Stony Brook University, in Stony Brook, N.Y. She is the president of SAGES, but her answers reflect her own personal opinions.

Benjamin K. Poulose, MD, MPH The Robert M. Zollinger Lecrone-Baxter Endowed Chair in Surgery and chief of the Division of General and Gastrointestinal Surgery at The Ohio State University Wexner Medical Center, in Columbus. He is the current president of the Americas Hernia Society.

Disclosure: Research support from Advanced Medical Solutions and BD; salary support from the Americas Hernia Society Quality Collaborative.

Guy Voeller, MD Professor of surgery at the University of Tennessee Health Science Center, in Memphis.

Ajita Prabhu, MD Department of General Surgery, Cleveland Clinic, in Cleveland.

Disclosure: Speaking and research support from Intuitive Surgical; consultant to Verb Surgical.

If no disclosure is listed, the panelist reported that he or she has no relevant financial conflicts of interest.

GUY VOELLER, MD: DISAGREE I

am really tired of all these guidelines. Hernia, lap cholecystectomy, whatever—I hate them. They are too long and tiring to read, and are usually based on flimsy data. Laypeople (i.e., lawyers and hospitals) see them as “standard of care,” which they are not. They are a waste of time for the most part. Practicing surgeons never read them and it has become an ego thing for the many of the people who make up the guidelines. They serve no real purpose and need to be stopped, now! That’s how I really feel. Does that mean some of what is in guidelines is not useful? Not at all. I think some of the points in so-called “guidelines” could be more effectively communicated than what occurs with guidelines as they are presently done. It is like putting something on the OR wall for all to read because it is important for all to read.

No one reads that stuff.

I think that guidelines can provide some general ideas for how to approach the repair of hernias, particularly when surgeons are new to practice and trying to find their way. I also think it is important to tailor operations to the specific clinical scenario/patient, which may require performing surgery that is different from the guideline at times, and that is OK, too.

AJITA PRABHU, MD: AGREE

AURORA PRYOR, MD: AGREE Guidelines

use an evidencebased approach and expert consensus to review the literature and help others to understand where evidence is substantial and where it is not. Well-written guidelines discuss when a specific approach is favored and when it is not. That said, guidelines are not rules, and each surgeon and patient should review them for an individual’s specific situation to make the best choice for that patient.

With the COVID-19 pandemic and reshuffling of staff, priorities and surgical schedules within hospital systems, it is apparent that a need for a new definition of “elective surgery” is necessary.

The existing rules for elective surgery worked well when surgical delays were short.

However, as delays pushed back, patients waiting for “elective surgery” became increasingly DR. PRYOR: AGREE

symptomatic and some developed urgent surgical indications. Much as we have a leveling system for urgent cases, leveling should be considered for longer delays as well.

DR. PRABHU: DISAGREE I think surgeons should maintain their autonomy in determining which patients require surgery and the appropriate timing of that surgery. We are often tempted to neatly categorize everything, and in reality, patients don’t always fit neatly into a category. Once we start to remove that decision making from surgeons, there is an erosion in the trust of our professional expertise, and there is the risk for nonclinicians making these types of decisions.

One patient’s elective surgery may be another one’s urgent or necessary surgery. Right now, it is very subjective for sure. The thing I found interesting is that the hospitals came up with a new informed consent covering these issues during the pandemic, which make it seem that what we surgeons do in nonpandemic times is frivolous and unnecessary. The new consent says things like your surgeon has determined that during this pandemic, your surgery is necessary for your health and should be done in spite of the risks and other crazy things. A patient can “elect” to do any surgery—even surgery that if they do not do, they will die.

DR. VOELLER: AGREE

Elective surgery is elective surgery. The confusion arose when the terms “essential” and “nonessential” surgery were thrown into the mix. These are very subjective terms and difficult to define. States attempted to adopt these terms with enormous ramifications during the end of March and April as we struggled initially with the pandemic.

DR. POULOSE: DISAGREE

With elective surgery constrained

by COVID-19, all inguinal hernias that are not incarcerated but are causing the patient discomfort should still be repaired and surgery not be delayed.

DR. POULOSE: ON THE FENCE I wish it were that simple.

Certainly, during times of resource constraints, difficult decisions have to be made. In many conversations with which I was involved, “hernia” was often mentioned as the archetypical operation that was “nonessential” and could easily be delayed. This attitude is part of a much deeper problem regarding the perception of our field not being on par with other fields (enter Abdominal Core Health and Abdominal Core Surgery!). A very symptomatic inguinal hernia that is causing serious impairment of quality of life, but that may not be incarcerated or strangulated, should be an operation that should proceed without much delay. continued on page 20

20

ON THE SPOT

GENERAL SURGERY NEWS / AUGUST 2020

The Art of Herniology

now with the financial impact of COVID-19, each surgeon should try to practice the most cost-effective medicine possible.

continued from the previous page

I rarely agree with any statement that begins with “all.” In general, I think symptomatic patients should be undergoing surgery with the appropriate expectations set for the possibility of contracting COVID-19 (which is true for all interactions when someone chooses to leave their home). If patients are able to reduce their hernias on their own and they are minimally symptomatic, I think it is fine for them to wait if that is what they would prefer.

DR. PRABHU: DISAGREE

DR. PRYOR: ON THE FENCE This

really depends on your local resources and COVID-19 burden. If you have a system that is very taxed, these patients can be delayed. If you have resources, they should have surgery. Inguinal hernia patients add little burden to hospital resources, as they are usually outpatient procedures. As long as there are staff and OR availability, and appropriate safety measures are in place, these procedures should be done.

We are here for the patient and to relieve discomfort. If the patient desires surgery and the hospital allows it, then we should help the patient. That is what we are here to do. This applies to the previous question in that the patient may not see this surgery as elective, while the hospital or the ACS [American College of Surgeons] or whatever ruling body that is in charge may label it as elective. The complicated scoring systems that these organizations came up with to decide if a surgery was truly elective were ridiculous and so out of touch with the reality of a busy hospital. Our hospitals never used them.

DR. VOELLER: AGREE

Given the inherent complexity in determining the true cost of health care in the United States, surgeons should not be held accountable for the costs incurred by their operations.

We are decision makers who can directly affect costs to the health care system. Particularly DR. PRYOR: DISAGREE

GUT REACTION

European hernia guidelines

DR. PRABHU: AGREE There

is currently no playbook for surgeons during their training that helps to understand and navigate all of the layers of complexity that ultimately contribute to the cost of health care. Often, when I have

The problem is that expensive surgical technology keeps moving us forward andd the reimbursement keeps going the otherr way—for the surgeon and the hospital.

—Guy Voeller, MD tried to drill down to get answers to these questions, it is even difficult for health care administrators to explain the factors that determine cost. Our system is simply too unwieldy and also lacks transparency, so to expect surgeons to be held accountable is likely shortsighted.

That said, I do believe that surgeons should consider the relative costs of the disposables, devices, etc., that we use in surgery, and we should make decisions that we feel are beneficial to our patients but also avoid excessive cost. That is the small part that we can contribute.

DR. VOELLER: DISAGREE With COVID-19 changing the face of health care and bundled payments coming fast and furious, surgeons will have to be held accountable.

There simply will not be enough money. The problem is that expensive surgical technology keeps moving us forward and the reimbursement keeps going the other way—for the surgeon and the hospital. There is going to have to be good data to use expensive technology or it will not be allowed, similar to other countries with government-controlled health care. As Dr. Adrian Park recently wrote, the fee-for-service as a system of payment is so far in the rear view mirror as to be a quaint memory. We are moving to a global budget or capitated system that will evolve into a model that will use population health metrics to determine bundled payments

Worst surgical complication I’ve seen recently

Resident and fellow education during COVID-19

that the hospital will receive, to then be divided with the surgeon.

DR. POULOSE: DISAGREE We are some of the biggest spenders in health care, but we are decoupled from the actual payment. During an operation, I could choose to spend $150 on mesh for an abdominal wall reconstruction or $15,000 on mesh for that very same operation in the same patient. The discretion is nice, but wouldn’t it make much more sense to have a great reason (based on sound information) to justify the $15,000 spend? Conversely, if you can’t demonstrate that great reason, why wouldn’t you choose the less costly option if it produces the same result? If we showed that these decisions were tied to our own reimbursement, there would be a true revolution in cost containment!

Biosynthetic (i.e., resorbable) meshes hold the key to the future of hernia repair.

DR. PRYOR: DISAGREE These products have their place in certain procedures and clinical settings, but they are not, in my mind, the solution for every hernia.

The concept is powerful: a mesh that maintains its structural integrity while the body’s tissue remodeling machinery is at work and then the mesh goes away. Just like at the dawn of the biologic mesh era, though, initial enthusiasm seems to be tempered a bit by the high up-front cost of these products and unclear long-term benefit. Unintended consequences have arisen: Some biosynthetic materials cause such an intense inflammatory reaction over time, which can also cause issues. Alarmingly, there is the connotation that all of these products can be used at will in contaminated situations. This is not the case. Many of the longer term absorbable biosynthetics behave like heavyweight polypropylene upon implantation and should be avoided in contaminated DR. POULOSE: ON THE FENCE

Biggest waste of money in the ER

Good reading for residents and fellows “Priced Out: The Economic and Ethical Costs of American Health Care”

by Uwe E. Reinhardt Your generation will have to care.

Excellent, well done

Death

Suffered greatly; immense challenge

Automatic ER-to-ER transfers instead of direct admission

Usually well done

Not much as we delayed elective practice!

Tons of ICU experience, not much time for anything else

Tons of personal protective equipment for all patients

Something not work related: “American Dirt” by Jeanine Cummins

Guy Voeller, MD

Waste of time

Death

Should continue; residency is short

CT scanner

“The House of God”

by Samuel Shem (pseudonym)

Ajita Prabhu, MD

Thorough

A huge common bile duct injury

Evolving

Diagnostic imaging and tests

“The Unwinding of the Miracle”

by Julie Yip-Williams

Benjamin K. Poulose, MD, MPH

Aurora Pryor, MD, MBA

21

AUGUST 2020 / GENERAL SURGERY NEWS

The concept is powerful: a mesh that maintains its structural integrity while the body's tissue remodeling machinery is at work and then the mesh goes away.

—Benjamin K. Poulose, MD situations until better data can demonstrate that it is safe. Err on the side of safety. Patients should be carefully followed over time with each and every implant, in my opinion; if our regulatory system doesn’t do that effectively for us, it’s our moral imperative to do it on our own.

happen. It’s kind of amusing—we are so willing to completely change our practices, how we do surgery, the way we eat, the way we obtain rides for a night out on the town, the way we communicate with everyone due to changes in

technology, yet for some reason this is what we hold onto as something that shouldn’t change? It’s crazy! It’s time to move on. The next things that should go are physical interviews for fellowship—we are already in great amounts of debt as resident surgeons, let’s not automatically make it worse.

Although we have done a great job of transitioning to virtual this year, there is still an amazing camaraderie and brainstorming that come from meeting in person. The unofficial conversations and mentorship are DR. PRYOR: DISAGREE

At this time, there is no objective evidence to suggest that biosynthetic mesh materials hold the key to the future of hernia repair. What we do know is that they are more expensive than synthetic mesh, and there are no head-to-head comparisons between biosynthetic mesh and synthetic mesh to recommend their use. Although every new technology deserves a fair evaluation through clinical experience (registry-based outcomes) and comparison with the existing standard, biosynthetic mesh has not undergone any comparison whatsoever to help justify the added cost.

We just don’t have enough information for this to be our position.

really valuable. I do think, however, that we will see a decrease in travel and an increase in the number of meetings that are held virtually.

There are certainly aspects of professional society meetings that are beneficial, but the reality is there are so many more ways to share information now, and the in-person meeting feels a bit dated. There are lots of avenues to connect, and to be able to do that without all of the expense and hassle of travel seems very appealing.

■ DR. PRABHU: AGREE

DR. PRABHU: DISAGREE

FOR COMPLEX HERNIA REPAIRS

Durable is Beautiful

I don’t know that I would say they hold the key, but if better ones than we have now can be developed, it is definitely something to shoot for in hernia repair. Currently, we don’t have ones that work for everyone, and you cannot predict who will get a recurrence once the mesh is gone. People don’t like permanent mesh with all of the lawyers on television telling them it is bad (which it is not). The biosynthetics we have now are so crude and rudimentary compared with what will be developed in the future, so I hope they will be one of the keys to the future of long-lasting, good hernia repair.

DR. VOELLER: ON THE FENCE

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National conferences should completely move to virtual meetings.

We just had the MISS [Minimally Invasive Surgery Symposium] meeting in a virtual fashion, and it was great! However, although virtual meetings are nice, the camaraderie that develops, the ideas that are exchanged, and all the other things that happen when people come together are too important to give up forever.

DR. VOELLER: DISAGREE

It’s a huge culture change but one that needs to

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DR. POULOSE: AGREE, 100%

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22

OPINION

30 Years of Hernia continued from page 11

the inguinal floor by sewing the triple layer of internal oblique muscle, transversus abdominis muscle and transversals fascia superiorly to the inguinal ligament and iliopubic tract inferiorly. The problem was that to properly do this, one must incise the posterior wall of the inguinal floor, and to do that, the cremasteric muscle must be resected. Both of these steps were often not done in the United States and an “imbrication” of poor tissues was done, leading to high recurrence rates.

In 1983, at the early part of my residency, the Rand Corporation of California published a paper showing that the failure rate for primary inguinal hernia repair was 10% nationally. This received a lot of attention and a spotlight was placed on inguinal hernia repair. This led to certain of my teachers introducing me to the mesh-based repair being popularized at the time by Dr. Irving Lichtenstein.

The history of the Lichtenstein repair is interesting. Dr. Lichtenstein started doing the “tension-free” repair in 1984. Up until that time, he performed a modified Bassi-

GENERAL SURGERY NEWS / AUGUST 2020

Congress of the American College of Surgeons, and each year, Dr. Lichtenstein would have a small corner in the poster section. He would stand in his long white coat showing a video of his tension-free, ambulatory repair, and surgeon after surgeon would come by to learn this technique. He truly was a master at marketing a very valid concept that remains the main method of open inguinal hernia repair 30 years later. The recurrence rate has now been reduced from the 10% found by the Rand Corporation in 1983, to the 1% to 2% with the Lichtenstein repair.

In 1974, Dr. Lichtenstein described the plug repair for femoral and recurrent hernias where there is usually a small defect while the rest of the repair is intact.

Instead of tearing down the entire repair, he thought a rolled piece of mesh could “plug” the defect. In 1990, he reported on more than 1,400 recurrent hernias successfully repaired using this method. This experience led to the development of the plug-and-patch repair by Drs. Ira Rutkow and Alan Robbins in 1990, and the introduction of the bilayer Prolene Hernia System (Ethicon)

by Dr. Arthur Gilbert in the 1990s.

The key is for a surgeon to learn one of these techniques properly and your patients can do well. ni repair, and reported his experience with 6,000 repairs.

Dr. Lichtenstein reported that Dr. Richard Newman introduced him to the tension-free repair, a technique Dr. Newman had started doing in the 1970s, but which he had had trouble getting published. Dr. Newman had done more than 1,600 tension-free repairs starting in the 1970s, based on Dr. Francis Usher’s work in 1960. Interestingly, Barnes reported in 1987 an 11-year series of tension-free repairs and Capozzi published a 10-year series of 745 tension-free repairs in 1988. (Dr. Robert Bendavid reports that we can actually go back to Dr. Don Acquaviva in France, in 1944, for the first mesh-based repair, in which he employed a nylon mesh prosthesis shaped like the key-hole meshes with tails, and these are used today.)

Dr. Lichtenstein wrote that “any attempt to approximate the semirigid transversus tendon forcibly to the rigid tubercle, the iliopubic tract, Poupart’s or Cooper’s ligament, whether it be by the Shouldice repair or the McVay approach, inevitably results in distortion of the anatomy and tension on the suture line.” Dr. Lichtenstein popularized the term “tension-free” and the concept of ambulatory inguinal hernia repair. (That’s right, until Lichtenstein, people stayed in the hospital after inguinal hernia repair for several days.)

I remember as a young surgeon going to the Clinical

In the United States, the most common open inguinal hernia repairs at present are the Lichtenstein, plugand-patch and the Prolene Hernia System. The most recent marketing data show that of the three most common open mesh-based repairs, 25% are Lichtenstein, 18% plug-and-patch, and about 6% for the Prolene Hernia System. There have been 15 to 20 randomized prospective trials comparing these three repairs, and they all show no differences in early or late complications, pain, return to activity or recurrence. The key is for a surgeon to learn one of these techniques properly and your patients can do well.

As a resident, I was also taught, by Dr. Eugene Mangiante, the open posterior approach to the inguinal floor (described by Annandale in the 1800s and redescribed

by Cheatle and then Henry in the early 1900s and popularized by Dr. Lloyd Nyhus in the United States and by Jean Rives and Rene Stoppa in Europe). The open posterior approach to the inguinal floor, however, was not a commonly done operation, especially in community hospitals in the 1980s. This changed with the introduction of laparoscopic inguinal hernia repair around 1990. As the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs were developed, those of us who were very comfortable

with the open preperitoneal repair immediately tried to mimic the principles of a sound preperitoneal repair using the laparoscope. This took a little while to mature, but it was soon apparent that it could be done, and that the laparoscopic repair, when done properly, gave equal results with respect to recurrence compared with the open mesh-based repairs mentioned previously. [See “Laparoscopic Techniques for Hernia Repair: A History of Ups and Downs,” GSN, March 2014.]

In addition, randomized trials in hundreds of patients like the ones done by Jeekel (2010) and another by Eker (2012) comparing TEP with Lichtenstein repair showed the laparoscopic repair had less postoperative pain and less impairment in sensibility (both statistically significant), faster return to daily activities, and similar costs in addition to similar recurrence rates.

More importantly, there was less chronic pain with the laparoscopic approach.

The problem with the laparoscopic approach to inguinal hernias was that it was difficult to do without a lot of dedication and time, and practicing surgeons could not afford to take the time to get over the steep learning curve. Many were not familiar with the open preperitoneal repair, and when you add to that the technical difficulty of getting good at the repair, this meant the laparoscopic repair was done less frequently than the open repair, despite the studies showing the superiority of the laparoscopic approach when done properly. The laparoscopic repair comprised 20% to at most 30% of repairs. This percentage has now changed with the introduction of the robot. There are many surgeons now doing laparoscopic robotic inguinal hernia repair who were not able or comfortable with doing it with straight-sticks laparoscopy. The latest marketing data show that the minimally invasive approach to inguinal hernia repair, both laparoscopic and lap‒robotic, now comprises about 50% of inguinal hernia repairs, with more straight-stick laparoscopy than robot. Even though we have recent studies hot off the press showing the robot is not superior to straight-stick laparoscopic inguinal hernia repair, I predict it will continue to grow, as residents and practicing surgeons can more quickly get over the learning curve with the robot.

We now have come full circle with my 35-year trip through inguinal hernia repair in that the mesh that was introduced by Lichtenstein for tension-free repair in the 1980s is now being questioned for hernia repair. Fortunately, when one looks at studies (Ann Surg 2002;235[3];322-332; Br J Surg 2002;89[1]:45-49; and many others) that compare mesh with non-mesh repair for inguinal hernias, we find that mesh-based repairs always have statistically significantly fewer recurrences with a risk reduction of 75%; complication rates are the same for mesh and non-mesh repairs; and, most importantly, the incidence of chronic groin pain is the same for mesh and non-mesh repairs. I think at present where we are with inguinal hernia repair is best summed up by the recommendations of the Danish Hernia Database (www.herniedatabasen.dk). Based on data from 10,000 inguinal repairs a year, they recommend the use of mesh for primary inguinal hernia repair, laparoscopic or open depending on the surgeon’s expertise, laparoscopic has less acute and chronic pain, and tissue-based repair is not recommended.

Have we moved the needle in inguinal hernia repair and in which way? After reviewing the above, I think my answer is yes, and in the positive direction. We have good, safe ways to repair inguinal hernias with low morbidity.

In addition, many things that help us do a better job of inguinal hernia repair now weren’t even considered when I was a resident. Tremendous things like the Americas Hernia Society (AHS) and the Abdominal Core Health

23

AUGUST 2020 / GENERAL SURGERY NEWS

Quality Collaborative (ACHQC) now have our own journal devoted to hernia. We have social media dedicated to hernia repair. We have hernia specialists who devote the vast majority of their time to hernia repair. We have a plethora of meshes all trying to help us cure our patients of a disease that can be debilitating. We have a tremendous collaboration now with our Asian and European colleagues through their hernia societies.

We have apps on our phone that we can use with our patients to help them understand the risks of hernia surgery.

Certainly, there are things that I think will need to be addressed in the next few years. I think with the issues around mesh that are common today, it is critical that surgeons learn an open autogenous repair so they can offer patients a non-mesh option. This calls for what Dr. Adrian Park and his colleagues recently wrote about: true engagement with the surgical patient (Surgical Innovation; June 15, 2020; doi.org/10.1177/1553350620936004).

The patient may want to take on a slightly higher chance of recurrence in exchange for avoiding mesh use for whatever reason.

In addition, as AHS President Ben Poulose makes clear in his address, cost containment will be more and more of an issue in hernia repair. Bundled payments will come to hernia repair just as they have with heart bypass, total joint replacement and other operations. Dr. Park, who I mentioned above, is professor and chairman of the Department of Surgery, Anne Arundel Health System, Johns Hopkins University School of Medicine, in Baltimore. They are first in line to have to deal with new Centers for Medicare & Medicaid Services guidelines and things we other surgeons will later have to confront.

Dr. Park told me recently that volumebased, fee-for-service as a system of payment is so far in the rear view mirror as to be a quaint memory. He said they spent some time with a â&#x20AC;&#x153;fee for valueâ&#x20AC;? payment model before moving on to a global budget or capitated system that will evolve into a model that will use â&#x20AC;&#x153;population healthâ&#x20AC;? metrics to determine those bundled payments. He ended by saying this is another way to say we are many stops past the ancient reality of surgeons having access to any OR device, instrument, mesh or other supply they might request.

It is amazing that inguinal hernia repair has gone from the â&#x20AC;&#x153;internâ&#x20AC;&#x2122;s caseâ&#x20AC;? to what we see has occurred over the past 30 years.  It is important for surgeons to master techniques that serve our patients well while not disregarding the costâ&#x20AC;&#x201D;ultimately our patients are the â&#x2013; ones paying for it. â&#x20AC;&#x201D;Dr. Voeller is a professor of surgery at the University of Tennessee, in Memphis.

Readmission continued from page 15

extended to at least 60 days in the Centers for Medicare & Medicaid Servicesâ&#x20AC;&#x2122; Hospital Readmissions Reductions Program, which reduces reimbursement by up to 3% to hospitals with excessive readmissions within 30 days of discharge.

The investigators estimate that the annual cost of unplanned readmissions totaled more than $90 million per year.

After controlling for confounders, the predicted mean difference in cumulative costs and length of stay (index

admission plus readmissions) were $12,189.70 higher and 6.1 days longer for patients readmitted within one year.

Generally, patients were between the ages of 45 and 65 years (49.1%) and most were female (58.8%), nondiabetic (80.81%) and not obese (77.54%).

One-fourth of the initial hernia repairs were done laparoscopically and mesh was used in 88% of cases. Readmitted patients did not differ in age, sex, income quarter, obesity and hospital characteristics.

The study used administrative data, particularly billing codes with the

potential for misclassification. The authors tried to minimize this bias by using the chronic condition indicator to define new cases of incisional hernia and complications occurring during the index hospitalization and readmission, and only included readmissions when a complication was listed as the primary diagnosis code.

The study was originally reported as an oral presentation at the 15th Annual Academic Surgical Congress in February 2020, and was published in June in the Journal of Surgical Research â&#x2013; (2020;255:267-276).

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24

OPINION

AHS President continued from page 11

support the herd coming to graze every day. The shared resource is depleted through the collective actions by many acting in their own self-interest.

The shared resource in health care is simply whomever is paying for it. So, who is funding our health care commons?

Economist Uwe Reinhardt summed it up best in his work “Priced Out: The Economic and Ethical Costs of American Health Care.” The main “checkwriters” of American health care include

GENERAL SURGERY NEWS / AUGUST 2020

government-run health insurance programs, private employers and private insurers. Reinhardt states: “None of these final check writers actually pays a single dime for health care. They all recover their outlays from the budgets of private households.” His is a shocking revelation. The situation becomes even more shocking when one realizes that health care costs contributed to the biggest percentage increase (24.9%) in middle-class families’ household spending in the United States between 2007 and 2014, according to the Wall Street Journal (“Burden of Health-Care Costs Moves to

the Middle Class,” Aug. 25, 2016). This was at the expense of other household spending; Health Affairs noted that health care costs have wiped out a full decade of wage increases (2011;30[9]:1630-1636).

As many of you have done, I called several patients whose operations were postponed due to COVID-19. As I worked through the list, several patients informed me of their job losses and furloughed status. They would be in no shape to undergo an elective operation given the out-ofpocket expense. Having 40 million working Americans file for unemployment should jolt everyone into rethinking how

we can insulate our friends, colleagues, families and patients from future losses.

It has become quite apparent that most Americans were living from paycheck to paycheck before the pandemic, paying a lot in health care expenses, and are now in a very difficult financial situation during the pandemic.

Determining whether a treatment we offer to patients has real value is extremely challenging. If we collaborate, we can generally agree on some outcome measure that can help inform our practices. On the other hand, agreeing on cost remains difficult. At best, it is so hard that most of us give up and just move on. At worst, we twist costs favoring our own biases in formal analyses. “Cost containment” efforts are generally limited to local efforts meant to benefit hospitals or practices. If cost containment were so effective, it’s unclear why the United States has the highest-priced health care in the world, surpassing $11,000 per capita—nearly double that of most other nations! When asked what the federal government does when it needs additional funds, the former chair of the Federal Reserve, Ben Bernake, noted, “We simply use the computer to mark up the size of the account.”

The COVID-19 crisis has laid bare one of the pillars of our health care economy that supports this high cost care– elective procedures. The New York Times reported that Mayo Clinic produced $1 billion in net operating revenue in 2019 (“Hospitals Knew How to Make Money. Then Coronavirus Happened,” May 15, 2020); it expects to lose $900 million this year due to suspension of elective procedures.

Many things drive spending in our health system, but surgery remains one of the biggest. According to the Health Care Cost Institute, surgical inpatient admissions consisted of 24% of all admissions in 2018 with an average price of $43,810 compared with a medical admission of $19,672. For outpatient spending share, surgery is the clear winner at 37%. With one in four working Americans filing for unemployment—and many losing health insurance—large numbers of patients will not undergo needed elective procedures anytime soon. Unlike the federal government, our patients, practices and hospitals do not have the option of using a computer to simply mark up the size of bank accounts.

We should be doing everything we can to limit the financial impact of our highpriced health care system on our own patients’ household budgets. Yet there are few analyses to evaluate the trade-offs involved if an expensive product, approach or technique has some marginal benefit. If you are the decision maker and there aren’t any perceived negative consequences to a high-cost decision (unchecked grazing

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AUGUST 2020 / GENERAL SURGERY NEWS

on the commons), you may very well be willing to spend the cash regardless of the outcome or price. A hypothetical modernday example can help illustrate.

Suppose we wish to evaluate the “best” vehicle to get to the grocery store from your house. The two vehicles we want to test include the 2020 Ferrari F8 Spider and the 2020 Honda Accord Sport.

We set up a randomized controlled trial assigning 200 households the Ferrari or the Honda, with its primary outcome measure being the average travel time from household to the grocery store parking lot. The trial is performed without a hitch, and the results are overwhelmingly in favor of the Ferrari—the travel time was reduced by 35%! There was even added benefit for the Ferrari group: They reported other drivers and pedestrians gawking at their F8 Spider at intersections. Some even took pictures of the beautifully crafted car. All participants received their groceries regardless of vehicle type. A commentary article was copublished after the well-written description of the trial results, pointing out that the 2020 F8 Spider costs $274,280 while the 2020 Accord Sport costs $26,830. If we were insensate to the cost of the F8, many would go for it.

In reality, however, most households will purchase the Accord Sport instead, even if it takes more time to get to the grocery store and you don’t create a ruckus at stoplights. Why would people act this way with such a clear-cut, noncontroversial, evidence-based advantage for the F8? The answer is that the Accord Sport does a fine job of getting you to and from the grocery store at a far cheaper price.

Currently, our health care system allows us to drive the F8 Spider without really worrying about the cost! This is our health care tragedy of the commons, which is ultimately paid for by our patients. The consequence of inaction is

LETTER TO THE EDITOR

2020 Ferrari F8 Spider

2020 Honda Accord Sport

clear—we will deplete the commons by increasing health care spending for each household. The pandemic exposed this economic fragility even further. Forty percent of Americans were unable to cover a $400 emergency expense and pay it off quickly according to the Federal Reserve. The Institute of Policy Studies found that nearly one in five U.S. households had either a zero or negative net worth (www.cnn.com/2020/07/03/ investing/american-dream/index.html).

If that weren’t enough, as health care prices continue to balloon, the checkwriters will soon discover that quality elective surgery can be performed at less cost outside of your local community, or even outside the United States. This will create unprecedented new levels of competition.

Amazon and Walmart are already bypassing local providers and sending

patients across the country to those who can provide the best value. Ashley Furniture Industries is pushing this further by sending both U.S. surgeons and their American employees out of the country for elective orthopedic surgery! Many large corporations long ago made the decision to cut expenses by moving manufacturing and services outside the United States where prices are cheaper, devastating many small businesses and livelihoods across America in the process. In this time of economic stress, you can bet that businesses will figure out ways to do more with less. The elective management of hernia is an area of health care that is primed for this disruption—whether we are ready for it or not. Patients tend to be ambulatory; operations are relatively low risk; and there is high volume.

We must also find a way to assess

Use of Mesh in Low-Resource Settings To the Editor:

Mesh repair of groin hernias has become the standard of care throughout the world, but other methods are acceptable.

I recently read an article titled “Groin Hernia Surgery in Low-Resource Settings—A Problem Still Unsolved” (N Engl J Med 2018:378:1357-1358). The authors lament that there is no-low cost mesh available in resource-limited environments and that mesh is, in fact, more expensive in these environments.

I am a missionary surgeon in Nigeria and currently spend six months per year overseas. Hernia repairs are one of our most common surgeries. I use a plug-and-patch method, with running 0-Prolene, with excellent results.

The unsolved problem the authors write about, namely low-cost mesh, has in fact been mostly resolved. I purchase commercial polypropylene mesh (equivalent to regular polypropylene mesh) for $40 per sheet (40 inches by 14 inches).

This is then cut into pieces, 3 inches by 5 inches, yielding 24

pieces. The smaller pieces are then heat sterilized or solution sterilized with equivalent results. If a surgeon does just a patch, then each hernia costs $1.68. If he does a plug and patch, then each hernia costs $3.34. These are reasonable numbers even in an economically depressed area.

For surgeons concerned about heat or chemical sterilization, I should mention that I have had no wound infections or recurrences in over 1,000 clean cases. Occasionally, in a strangulated hernia requiring bowel resection, an infection occurs. Despite these occasional infections, I have not had to remove mesh.

In summary, mesh repairs of groin hernias is possible even in resource-limited environments, providing a little time is spent obtaining and sterilizing the mesh.

Brian Camazine, MD President of Earthwide Surgical Foundation Henderson, Texas

the value of innovation in surgery fairly. An innovative product, approach or technique may improve beneficial outcomes or save time in a very useful way, but may be more expensive than what is currently available. We might be very willing to pay a premium despite new problems and costs inherent to the innovation. Laparoscopy is an excellent example. Our current concept of value defined as outcomes/cost does not capture innovation well. Since time savings can be critical to the appraisal of innovation, and translating time into cost is a murky business, we should modify the value concept as outcomes/(cost + time).

All of us care deeply about doing what is best for patients clinically. We should extend that sentiment to their health care costs over time. Improving outcomes and reducing costs is complex and difficult; it must also allow for true innovation. The simplest thing we can do right now is subject our decisions to the question: “Is there a less costly way to get the same result?”

We must start now, otherwise our patients suffer and the checkwriters will look elsewhere. Professional societies such as the Americas Hernia Society and Abdominal Core Health Quality Collaborative are uniquely poised to lead these efforts; we must set aside our differences to succeed.

It has truly been an honor to serve as the president of the Americas Hernia Society in a tumultuous period in history. I look forward to a bright future where we can overcome these challenges and foster meaningful innovation for the ■ benefit of our patients.

—Dr. Poulose is the Robert M. Zollinger Lecrone-Baxter Chair and chief, Division of General and Gastrointestinal Surgery. He is the current president of the Americas Hernia Society and director of Quality and Outcomes for the Abdominal Core Health Quality Collaborative.

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AUGUST 2020 / GENERAL SURGERY NEWS

Surprise Medical Bills: An Overview continued from page 1

an assistant professor at Washington University School of Medicine in St. Louis. “As a patient, you trust that if you have insurance you will be covered, but that is not how these scenarios are playing out.”

A surprise or balance bill can occur when a patient with health insurance unintentionally receives care from an out-of-network provider. When an insurance company and hospital or clinician don’t have a contract in place that sets payment rates, the clinician is considered “out-of-network” and the insurance company isn’t obligated to pay, Dr. Joynt Maddox explained. That often leaves patients responsible for the bill.

But how common are these types of charges?

An analysis published last year found that among almost 20 million privately insured patients, out-ofnetwork bills accompanied more than 40% of emergency department visits and inpatient admissions in 2016 (JAMA Intern Med 2019;179[11]:1543-1550).

A 2019 survey from the Kaiser Family Foundation estimated that 18% of emergency visits and 16% of inpatient admissions at in-network hospitals led to an out-of-network bill. Of inpatient admissions, surgical visits led to a higher rate of out-of-network charges, at 21%.

In an emergency or time-sensitive scenario, a patient will likely not have the ability to pick an in-network doctor or hospital. But what happens when patients do have time to shop for an in-network provider and facility?

Karan R. Chhabra, MD MSc, who studies the affordability of surgical care at the University of Michigan, in Ann Arbor, wanted to find out.

Dr. Chhabra and his colleagues analyzed bills from almost 350,000 patients who had gone to in-network surgeons and facilities for elective operations (JAMA 2020;323[6]:538-547). What he found surprised him: 20% of patients received an out-of-network bill. The average bill came to $2,011.

In other words, “out-of-network bills occurred just as often for elective surgeries as they do for emergency visits,” Dr. Chhabra said.

Dr. Chhabra’s team could only estimate the potential surprise bill stemming from these out-of-network charges because the data did not specify what portion of the out-of-network bill insurers ultimately paid. Some insurers, for instance, may cover part of an out-of-network bill whereas others may leave patients on the hook for the full amount.

The most worrying finding, Dr. Chhabra said, was that these patients had chosen in-network providers and facilities. Dr. Chhabra’s team found that the largest proportions of cases of potential surprise medical bills cases involved out-of-network surgical assistants and anesthesiologists, but other providers, such as radiologists and pathologists, also had a part.

Dr. Chhabra’s work aligns with other recent research that tracks out-of-network bills at in-network facilities. A 2019 study in Health Affairs also found that even when privately insured individuals received care at innetwork hospitals, they often still faced unexpected outof-network bills from specialists they didn’t choose.

“So, in the elective surgery setting, patients are getting charged thousands of additional dollars from a clinician they didn’t have an opportunity to pick,” said Dr. Joynt Maddox, who is also the co-director of her university’s Center for Health Economics and Policy. “Although the issue of surprise medical bills is not new, our recognition of how common it is has grown recently.”

Solutions for Surgeons

Congress would ensure patients being treated at innetwork hospitals pay in-network rates for bills under $750, even if an out-of-network provider was involved in their care. For bills of $750 and over, clinicians or insurers could opt to go through an arbitration process where an independent party would decide how much the insurer should pay the provider.

“We’re facing a classic scenario in which we need legislation, but the legislation proposed so far has gotten pushback from all sides,” Dr. Joynt Maddox said. “Physician and hospital lobbies don’t think the fixes give them adequate compensation, while insurance companies and patients may not think the proposals go far enough.”

With no national-level legislation, some states have adopted their own surprise billing laws with varying degrees of protections for consumers. California, for example, passed a law in 2017 that protects patients using in-network facilities from receiving a surprise p pp medical bill if a provider happens to be an out-of-network one. Patien Patients are only responsible for their regular regu in-net-

For Dr. Chhabra, “my biggest takeaway for surgeons is to try, when possible, to work with a surgical assistant who is in the patient’s network.”

Eileen Natuzzi, MD, an acute care surgeon in California, has another solution: complete price transparency.

Dr. Natuzzi ran her own surgical practice as an outof-network provider for many years. In her practice, a clear price tag accompanied each procedure.

“I set my rates based on a back calculation of my business costs and gave those rates to patients before their surgery,” Dr. Natuzzi said. She also told her patients the extent to which their insurance would cover her charges based on their plan, so patients knew how much their out-of-pocket expenses would be prior to surgery.

“There’s no reason consumers shouldn’t be able to get this number,” she said.

Dr. Natuzzi, however, didn’t become an out-of-network physician by choice. She says she was driven out because insurers stopped negotiatingg fair contracts with independent and small practices.

“When I did the math, I found I needed to be paid

‘In the elective surgery setting, etting, patients are getting charged ged thousands of additional dollars from a clinician they didn’t n’t have an opportunity to pick.’

—Karen Joynt Maddox, MD, MPH

Table 1. Rates of Out-of-Network Bills Across 7 Procedures Procedure

Overall

CABG

Colectomy

Lap Chole

Total Knee Replacement

Hysterectomy

Average bill, $

2,011

3,236

3,449

1,255

2,786

2,174

Frequency, %a

20

33

24

24

25

26

Table 2. Drivers of Out-of-Network Billing in Elective Surgery, by Provider Specialty Provider

Surgical Assistant

Anesthesiologist

Radiologist

Pathologist

Average bill, $

3,633

1,219

321

284

Frequency, %a

37

37

7

22

a

Figures don’t add up to 100%; some patients received out-of-network bills from multiple providers.

CABG, coronary artery bypass graft surgery Source: Dr. Chhabra’s analysis. https://ihpi.umich.edu/news/ihpi-briefs/surprisebilling.

150% to 200% of Medicare to survive, and insurers in California were only offering contracted rates of 85% of Medicare,” said Dr. Natuzzi, who is now working with a group of surgeons to study and address health care costs.

No Simple Fix Patients, doctors, policymakers, even insurers and hospitals agree that consumers need to be protected from these surprise out-of-network bills.

The challenge, however, has been finding a solution at a national level that all parties can agree on. Surprise billing legislation currently being considered in

work copay or deductible, and out-of-network doctors receive 125% of what Medicare pays or the average contracted rate for similar services in the area.

But Dr. Joynt Maddox does not see state laws as a solution to surprise medical bills. “Surprise medical bills are a symptom of a completely broken health care market,” she said. “We can patch the system and limit the bleeding, but it’s not solving the problem of what got us here—that the market isn’t working to limit costs of care due to hospital and insurer consolidation and a lack of transparency. That said, I hope the patches we come up with can save patients from medical bills that threat■ en their financial security.”

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GENERAL SURGERY NEWS / AUGUST 2020

If Only We Knew Then: Surgeons Offer Advice on Life, Careers continued from page 1

Residency, training and her first job gave Dr. Witherspoon, an associate professor at the University of Tennessee College of Medicine in Chattanooga, the tools and skills she needed to perform a broad range of operations. But she attributes her longterm success to the guidance and mentorship of colleagues and partners she had along the way. Even with the most supportive colleagues, however, there are a few areas she believes can be especially problematic for people early in practice:

Dealing with patient death and serious complications. “We tend to internalize our feelings, but that can kill our spirit.

I was encouraged early on to talk about bad outcomes with trusted colleagues; this is essential to maintaining focus and equilibrium in practice life.”

Losing an established patient to another surgeon. “Even if this bruises your ego a bit, you learn to get over it. Over time, my nurse and I have become adept at recognizing these patients, so we’re rarely as

surprised as we were early on.”

Patients who refuse treatment or fail to follow advice. “I don’t know the answer to this, but threatening these patients won’t change their mind. Communicating the outcome of various treatments or lack of treatment in a factual manner will at least leave you feeling that you’ve made your best effort.”

Ultra-perfectionism and children; you can’t have both. “I see this more in my female residents than my male residents,

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‘I see this more in my female residents than my male residents, maybe because I’m watching them more closely, but nothing washes shes ultra-perfectionism nism out of you like having a baby.’

—Laura ura Witherspoon, MD maybe because I’m watching them more closely, but nothing washes ultra-perfectionism out of you like having a baby.”

Grace F. Rozycki, MD, MBA, a professor of surgery at Johns Hopkins University, in Baltimore, introduced her talk with a proverb: “’Tell me a fact, and I’ll learn; tell me a truth, and I’ll believe; but tell me a story, and it will live in my heart forever.’ Looking back over my life, it’s a story. Here are some things I wish I’d known then”: The power of influence. As a young faculty member, Dr. Rozycki was concerned with achieving a title or some other signifier of power. At the time, she didn’t fully appreciate how influential her clinical work—in the OR, ICU, emergency department and trauma bay—was on the entire health care facility.

‘Mentees often ask me to teach them how to say no, but you say no every day, either to someone else or to yourself.’

—Grace F. Rozycki, MD, MBA “You can attain influence while having very little power. It’s the effect of one person or thing on another, is built on clinical competence and authenticity, and drives meaningful change in an organization,” she said. “Providing expertise in several venues increases your potential for influence and enhances your value to an organization.”

Smart goal setting. Early in her career, Dr. Rozycki had goals, objectives and to-do lists that she consulted. Looking back, she thinks it would have been more useful to identify specifically what she wanted to accomplish and why. A few self-directed questions can help hone in on priorities.

IN THE NEWS

AUGUST 2020 / GENERAL SURGERY NEWS

“Does this goal make sense in the current environment? Do you have the tools and skills to achieve it? Do the tasks you’ve undertaken align with your goals?

Mentees often ask me to teach them how to say no, but you say no every day, either to someone else or to yourself.”

Carving your own path. “This is something I wish I’d felt more comfortable doing, rather than basing my actions on what the competition was doing,” Dr. Rozycki said. “As surgeons, we have the stamina to move our lives forward even in the face of complex challenges; we need to exhibit strength, character and courage when facing conflicts.”

David B. Adams, MD, a professor of surgery at the Medical University of South Carolina, in Charleston, used points delivered by restaurateur Michael Shemtov at a commencement ceremony to frame his talk. “The best five-minute speech ever. He said three main things; here are examples of how those things played out in my life”: Don’t let someone tell you who you are; discover who you are. In his first job, as chief of surgery at the U.S. Navy Hospital Guantanamo Bay, Dr. Adams saw a patient who’d lost both legs after tripping a land mine. He’d thought the patient would survive, but he didn’t make it. This

led Dr. Adams to comb the literature as one would for a morbidity and mortality presentation. But there was no literature. With his colleague Bill Schwab, Dr. Adams set about creating the literature, doing a retrospective review of all such catastrophic injuries and establishing classifications.

‘You’re not defined by where you came from, but by who you want to be. Even though we were blue collar trained surgeons, we could compete with the blue bloods.’

—David B. Adams, MD “And I thought, but wait—we’re riding the bus. We’re not driving the bus.

We’re not allowed to create these classifications. But that’s the kind of person Bill was. You’re not defined by where you came from, but by who you want to be.

Even though we were blue collar trained surgeons, we could compete with the blue bloods.”

Don’t take no for an answer. In 1989,

the dawn of laparoscopy, Dr. Adams encountered Dr. Jacques Perissat at a convention. Intrigued, he asked his department chair about going to France for a couple of weeks to train with the laparoscopic pioneer.

“He didn’t think laparoscopy would go anywhere, but didn’t resist when I took two weeks’ vacation, traveled to Bordeaux, and trained with Dr. Perissat.

Sometimes you just can’t take no for an answer, but like many things in surgery, you will have to do a workaround.”

You don’t choose your timing; your timing chooses you. The same department chair who resisted sending Dr. Adams to Bordeaux called him into his office one day to discuss when he might be ready to be a program director. Reflecting on his training in the Navy and how that might compare with university training programs, Dr. Adams said maybe two or three years.

“He said he didn’t have that much time. Two weeks later, I was his associate program director.”

After his stint as a Navy surgeon, Frederick L. Greene, MD, a surgeon in Charlotte, N.C., and former chair of surgery at Carolinas Medical Center, was determined to go into academic medicine. But he had no sponsor or

‘I would try to compromise and be the peacemaker—that’s just my personality. But I could have been more proactive with some individuals, which I advise anyone in a leadership positionn to do.’

—Frederick L. Greene, MD mentor, and the few letters he wrote to academic centers went unanswered.

When a senior colleague invited him to join his small rural surgical practice, Dr. Greene accepted, but it felt like a bit of a letdown.

“I really wanted to be a teacher. But it turned out to be the best thing I could have done. In 1978, there were no cellphones and no beeper system; I had two offices and two hospitals 20 miles apart, and we were doing trauma every other night. I only stayed there two years, but it gave me so much information on how to deal with my colleagues in private practice and in academic positions.” continued on page 34

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OPINION

GENERAL SURGERY NEWS / AUGUST 2020

A Tribute to Health Care’s First Responders continued from page 1

work of thousands of other health care providers in our country.

But first, let me offer several historical footnotes, including concepts that were previously proven to be valid in dealing with a pandemic.

The plague doctors of the 14th century donned their own version of a hazmat suit to administer to the afflicted. They avoided touching the sick and potentially contaminated areas. When not working at their profession, they quarantined themselves.

The 1918-1920 Spanish flu came in two horrendous waves, the second wave being more deadly than the first. The young were the most afflicted, certainly in part because of crowding during World War I, as well as the deaths from cytokine storm induction. Five hundred million people were infected worldwide (28% of the world’s population) and 50 million died (10% mortality).

A towering figure of the time, Dr. Thomas Tuttle, born in Fulton, Mo., in 1869, was the commissioner of health for the state of Washington in 1918. In dealing with the Spanish flu, he made wearing face masks mandatory; he advocated social distancing; he encouraged home isolation and quarantining of individuals who had been exposed to the virus; he raised the notion of asymptomatic transmission; he warned of a resurgence of disease if restrictions were lifted prematurely. However, in an unfortunate prefiguring of our present situation, his efforts were met with great societal opposition, eventually causing his dismissal from the U.S. Public Health Service.

The 2014-2019 Ebola epidemics were prevented from becoming pandemics by enforcing isolation, quarantine, travel restrictions and, eventually, a vaccine. The stunning success of vaccination, initiated as early as 1796 by Edward Jenner, against a pandemic was made evident by the fact that it was responsible for essentially wiping out smallpox from the world. Although nowhere as successful, a flu vaccine has been available for the past 60 years.

Over the centuries, through repeated experience with pandemics, scientists have learned the vital importance of isolation, quarantine and face masks to inhibit transmission. Thus, the history of pandemics clearly indicated that when COVID-19 appeared in Wuhan, China, it would—if not met with preventive measures—spread throughout the world, and, that once the virus reached our continent, rapid implementation of proven methods of resistance and containment should have been mandated. This is not what occurred. Instead, as a nation, we suffered another Pearl Harbor, another 9/11. We rapidly lived up to the slogan, “America First,” as we reached the highest number of confirmed cases and deaths from COVID-19.

To deal with this grave reality, our health care system vaulted into action and true leadership emerged.

Seattle The first confirmed case of COVID-19 in the United States, in a man who had returned from Wuhan, was reported on Jan. 21, 2020, by Providence Regional Medical Center in Everett, Wash., a city north of Seattle. The first evidence of community transmission came on Feb. 28, when two critically ill patients hospitalized at EvergreenHealth in Kirkland, Wash., with unexplained lower respiratory infections were tested and found to be positive for SARS-CoV-2. One of those two patients died on the same day. It soon became evident that transmission within a local nursing home was one of the major contributors to early spread of the virus and a significant contributor to the early mortality of COVID-19. America watched as the national tragedy unfolded in a microcosm.

The first health care responders in Washington did more than observe; they acted, and they acted swiftly.

Within seven days after identification of the first case of COVID-19, EvergreenHealth initiated more than 10 protocols of response including establishment of a drive-through testing site, an inventory for accountability and preservation of personal protective equipment (PPE), conversion of hospital beds to ICU units with negative airflow, and communication networks linking health care workers and epidemiologists with patients and the public. Within days, the intensivists in greater Seattle had a text thread communication between the ICUs across the city on the number of cases, symptoms, clinical presentations, treatment strategies, and medical and staffing needs. Unprecedented stress faced the caregivers—the emotional impact of observing the isolation of patients, especially those soon to die, without being able to say goodbye to their relatives.

“I was glad to be able to be there with patients, but the isolation can be overwhelming.”

—Katherine Mandell, MD, general surgeon, Seattle “From the beginning, this has been a collective effort to respond quickly and exchange knowledge with our peers at every step, and we are extremely grateful for our partnerships.”

—Frances X. Riedo, MD, EvergreenHealth Medical Director of Infectious Diseases

New York City New York City (NYC) was inundated by COVID19; however, again health care workers, led by our fellow surgeons, rose to the challenge. There are many hospitals in NYC; NewYork-Presbyterian at Weill Cornell Medical Center is my example. The facility has 860 adult beds with 110 ICU beds; by April 15, at the peak of the epidemic in NYC, 560 beds were occupied by COVID-19 patients with half in ventilated ICUs. Hospital COVID19 capacity was created by cessation of elective surgeries

on March 15 and less urgent cases by March 27. ICU capacity was expanded to 230 with the potential of reaching 290 by converting ORs and recovery rooms into ICU units. Over 300 physicians and staff were deployed in this effort. A responders’ safety committee was established that initiated PPE changing areas and negative airflow work units. Backup personnel were recruited, including former chief residents from the past 30 years and Department of Surgery personnel not skilled in intensive care.

Telemedicine was initiated, and educational and communication activities moved to Zoom platforms. Some of the Cornell responders fell ill with COVID-19, and several relatives of staff and faculty, as well as a beloved breast surgeon, died of the disease. At present, Cornell is slowly recovering its care initiative, returning to elective surgery, justifiably proud of its achievements.

“The rapid dissemination of the new coronavirus pandemic created a situation of unprecedented emergency. Our lives were dramatically altered as we found ourselves in the center of a situation with many unfamiliar challenges, a great deal of apprehension, and an element of personal risk. The department came together in fighting this pandemic. I have been personally touched by the spirit of selfless altruism that has permeated the response of our faculty, residents and staff, and by former residents who have come back to help us.”

—Fabrizio Michelassi, MD, Surgeon-in-Chief, Weill Cornell Medical Center

Twin Cities, Minn.

A prime example of meeting the nation’s emergency call to action was the inventive steps taken by the University of Minnesota/Fairview Health Services for the Twin Cities of Minneapolis and St. Paul. Bethesda Hospital in St. Paul, which opened its doors in 1883, had been transformed into a long-term acute care hospital in 1989. In 2019, this aging facility was scheduled for a reduction in size, with its future in doubt. However, on March 20, the decision was made to convert Bethesda to the first Minnesota hospital dedicated exclusively to the care of COVID-19 patients. In less than one week, bed capacity increased from 50 to 90, consisting of 35 ICU beds with negative airflow capability and 55 medical–surgical beds to care for acute respiratory patients; additionally, rooms were wired for cardiac telemetry and C-arms to accommodate extracorporeal membrane oxygenation cannulation. Just as rapidly, volunteer hospitalists, intensivists, anesthetists, respiratory therapists, nurses and required support staff were enlisted, with surgeons in the forefront of this effort.

And 24/7 laboratory, radiology and pharmacy services were established. In just six days, on March 26, the first COVID-19 patients were transferred from other hospitals to Bethesda. By early April, four COVID-19 clinical research studies were established at this facility.

OPINION

AUGUST 2020 / GENERAL SURGERY NEWS

This effort, and similar accomplishments by health care first responders, working in concert with excellent state mandates initiating adherence to social distancing, self-quarantining of exposed individuals, obedience to regulations for working at home, and the closing of community facilities, allowed Minnesota to suffer, but not to be overwhelmed by, COVID-19.

“Despite an aged and physically limited structure, we succeeded at Bethesda to advantage the benefits of cohorting patients, to concentrate expertise, and potentially to allow other hospitals to maintain and resume their other functions.”

—Jeffrey G. Chipman, MD, Professor, Surgical Critical Care, University of Minnesota, in Minneapolis

American College of Surgeons The ACS rallied the surgery community, providing moral leadership, setting guidelines, and, above all, publishing fact-based, nonpolitical information.These efforts included launching a twice-weekly digital ACS COVID19 Update Bulletin to provide clinical guidance, ethical considerations, reviews of the latest clinical and research findings; first-person perspectives from surgeons around the globe; and messages from ACS leadership, as well as

referral to a new COVID-19 microsite accessible on the ACS website. The ACS issued guidance documents on, among other topics, recommendations for surgical management of elective operations during COVID-19, triage guidance for nonemergent surgical procedures, and other acute response measures.

The Journal of the American College of Surgeons was among the first scientific journals to call for and to publish COVID-19–related manuscripts. Other proactive ACS activities included the introduction of the ACSCOVID-19 Registry and a call put forth by the ACS “Operation Giving Back” for medical volunteers who could step forward if needed (over 500 surgeons registered). The registry will document the clinical data of COVID-19 patients who did and did not have surgery to evaluate the effect of surgery during the disease and to provide future guidance about when surgery is appropriate under such circumstances.

“In responding to this event, we just built upon the infrastructure that we have, which again is designed to try and serve all—not just all patients—but serve everyone involved with surgery.”

—David B. Hoyt, Executive Director, American College of Surgeons

Perspective As we consider this immense challenge to our civilization, I am certain that if there is unabated continuation of the current viral spread, another crippling wave of COVID-19, or a new epidemic, the surgical sector of the health care community will be there from the beginning to the end to serve our nation’s people.

Accolades, therefore, to all: the ambulance personnel; the ER workforce; the orderlies; the cleaners and other laborers who keep a hospital safe and habitable; the secretaries, receptionists and clerical staff; the nurse’s aides; the nurses; and the doctors who have been and continue to be the front line to combat the plague of our generation.

Kudos, cheers, thank-yous and tributes to health care’s first responders.

■

—Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.

Preventing Burnout During the COVID-19 Pandemic

By KATE O’ROURKE

A

ccording to Elke Van Hoof, a professor of health psychology and primary care psychology at the Vrije Universiteit Brussel, in Brussels, Belgium, and an authority in the fields of stress and burnout, the multiple stresses people are currently experiencing due to the COVID-19 pandemic will result in a secondary epidemic of burnout and stress-related absenteeism in the latter half of 2020.

At a recent webinar of the American Society for Metabolic and Bariatric Surgery, Rachel Goldman, PhD, FTOS, a licensed psychologist and consultant in private practice and a clinical assistant professor in the Department of Psychiatry at New York University’s Grossman School of Medicine in New York City, addressed care for caregivers to avoid professional burnout.

“For the past few months, we have been worried about a world where hundreds of thousands of people were dying,” Dr. Goldman said. “We were worried about getting sick and worried about others getting sick. So much about life as we knew it became uncertain. Maybe if you were a working parent, you also became a full-time employee and fulltime home schoolteacher, while protecting your family and perhaps your patients from the pandemic.”

“Pandemic fatigue” describes the intense tiredness and weariness that many people feel, and the irritability and disorientation of not knowing which day of the week it is, Dr. Goldman said.

Why is this taking such a toll? For many

reasons, but if you are working from home, you also don’t have mental breaks built into your day, you don’t have commuting time or transitions built into your day, and maybe you and your self-care are on the back burner.

A recent review and meta-analysis in the British Medical Journal reveals that in the past 20 years, other viral epidemics have caused psychological problems for health care workers (Br Med J 2020;369:m1642).

“The first research about quarantine in China found it can bring on insomnia, stress anxiety, depression, anger, emotional exhaustion and post-traumatic stress symptoms,” Dr. Goldman said.

Preliminary data from China during the COVID-19 pandemic show that 50.3% of health care workers reported depression, 44.6% reported anxiety, 34% reported insomnia and 71.5% reported distress (JAMA Netw Open 2020;3:e203976). In an online survey from Eagle Hill Consulting, conducted in April 2020, that included approximately 1,000 respondents from a random sample of employees across the United States, 45% said they were feeling burned out with one in four reporting feeling that way because of COVID-19.

To avoid burnout, people can take several steps. First, people need to focus on

what is in their control, which is behaviors, reactions and how they cope, and not on what is out of their control, which is daily stressors, other people’s behaviors and how other people react. Creating boundaries, checking in with ourselves, self-care, and disengaging from social media or the media in general are all important.

“Self-care” is a broad term that encompasses just about anything you do to be good to yourself. It’s about knowing when your resources are running low and taking a step back to replenish and recharge. ”Self-care is a necessity, not a luxury,” Dr. Goldman said. “Individuals who do not participate in self-care will eventually burn out and not be productive in any aspect of life, personal or professional. We will eventually get sick.”

Dr. Goldman suggested that a good place to start is with our key health behaviors which include sleep, water, physical activity, diet and stress management.

“Have a toolbox full of tools that you can pull from. Have at least three stress management tools, one of which is something internal, something that you don’t need anyone else or anything else for,” she said.

Your coping toolbox could include things

‘Individuals who do not participate in self-care will eventually burn out and not be productive in any aspect of life, personal or professional.

We will eventually get sick.’

—Rachel Goldman, PhD, FTOS

such as cuddling a pet, reaching out to a friend, meditation, listening to music, walking, exercising, mindfulness, breathwork, journaling or turning to a spiritual community. “Check in with yourself on a regular basis. Ask yourself, ‘What do I need right now to be the best me?’ Ask yourself how you are doing with your health behaviors,” Dr. Goldman said. “It’s OK to say no in order to say yes to you and your health.”

Dr. Goldman talked about a “healthy selfishness,” which might seem like an oxymoron, but it is knowing what you need to do and allowing yourself to do it. “Taking care of you and your health is not selfish. The behaviors that we participate in everyday that contribute to our survival are acts of selfishness. The act of eating or sleeping is selfish, but if we didn’t, we wouldn’t survive,” she said.

“We need to participate in these behaviors as well as others to be healthy, such as taking time out of our day for us, for ‘me time,’ and to relax or de-stress. These behaviors allow us to be healthy so we can be healthy and available for others.”

Scheduling daily “me time” and making it part of our daily routine is important. Creating breaks throughout the day to rest or recharge are critical, especially during this trying time of the COVID pandemic. Similar to being on an airplane, where you have to put your oxygen mask on yourself before you can help other people, individuals need to tend to their selfcare before they can help ■ other people.

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32

RESIDENT WRITING CONTEST

GENERAL SURGERY NEWS / AUGUST 2020

The Era of Specialization Is Upon Us A Call for Transformation in Surgical Education

By ROBERT NAPLES, DO

the future general surgeon, it remains important for the current trainees to get exposure to these novel ideas that may help shape the field. This leaves general surgery residency programs with a difficult task in attempting to provide appropriate exposure to trainees. Yet, what if general surgery training became specialized in a way, in order to accommodate these demands and needs for trainees?

The structure of general surgery training should be altered to adopt a 4+2 model for our training. In this system, trainees would spend four years gaining a broad experience in the foundational concepts of general surgery. This includes vascular, thoracic and plastic surgery rotations in addition to core general surgery rotations such as trauma, minimally invasive surgery and surgical oncology. Then, two years would be spent in the specialized surgical field of the trainee’s choice, equivalent to a fellowship.

For those surgical fellowships that only have one year of training, it would give trainees a longer time dedicated to their desired specialty, allowing for increased experience, exposure and autonomy prior to embarking on their own. For those fellowships that have two additional years of training, the 4+2 model would be an opportunity for trainees to complete their training a year earlier without compromising their education.

This would be a significant upheaval in the present system, but it would not disrupt the foundation of general surgery training; instead, it would allow the development of a new scaffold from which to build the future of surgical training.

Research has become a major point of emphasis for many residency programs. The proposed 4+2 model would still grant residents the option for dedicated time away from clinical duties to pursue these research opportunities. Although this would be an additional year or two in their training, it maintains the continuity of the current model. Trainees can get the necessary experience that allows them to learn how to conduct research for a possible career as an academic surgeon.

Furthermore, this time off from clinical responsibilities also provides residents with the opportunity to obtain raduating general surgery residents are advanced degrees or other certifications. By not tampernot prepared for independent practice.” ing with this important time period, residents are still This sentiment echoes in the halls of every trainafforded with the ability for professional growth. ing institution and incessantly torments surAlthough much of the policymaking and decision gical residents. Whether there is truth in this making in the training of residents is catered toward statement or whether it is just folklore passed the academic surgeon, rural general surgeons are in desdown from earlier generations remains to be perate need of the next generation. Over the past couseen. Although every generation believes ple of decades, there has been a decline in the number they are the “best,” the transformation in of graduates entering rural surgery. If this trend continsurgical training has come a long way. In ues, there will be few surgeons left to provide care for the past two decades, residents have gone from “living” those in rural America. In an attempt to combat this in the hospital to the current evolution of complicated impending crisis, one of the strengths for this model call schedules to reduce duty hours and enhance patient could lie in the training of rural general surgeons. The safety. While it is unknown whether this transformation training for this type of surgeon remains challenging has contributed to the universal feeling of unpreparedand has been a focus of many surgical educators across ness in our future surgeons, this sentiment strikes at the the United States. This has been such a hotly debatcore of surgical educators everywhere and heightens the ed topic that some residencies have created a specific awareness that something is intrinsically wrong in the track for those interested in pursuing this route. Howpresent surgical training. ever, with the 4+2 model, a resident would not need to We must embark on the next major change to ensure identify this interest as early as they do now. Instead, the appropriate training of the current generation they could gain the usual broad experience in their resof residents. Therefore, surgical education must stop idency program for the first four years and then enter ignoring the inevitable and modify the current training a specific rural general surgery training track for the approach to improve surgical education in this modern remaining two years. era. If done properly, maybe we can get back to a sense The current system forces students to choose their of confidence in our newly trained surgeons. career path after their third year in medical school, when Surgical specialization has progressed like cellphones; they have a limited experience in surgery. By allowing 30 years ago, cellphones were rare but today they are trainees to choose after three years of a robust and wellubiquitous. Specialization has become a vital comporounded general surgical experience in residency, more nent in the advancement of the surgical field and care of graduates may opt for the rural general surgery route, as it the complex patient. The “true” general surgeon is vandoes provide advantages over the specialty route that are ishing before our very eyes. Ever fading are the carotid not seemingly evident in medical school. Furthermore, endarterectomies and skin grafts that used to be synthis would supply a major need in general surgery. To onymous with the general surgeon. Surgery has creattract trainees into this field, financial or employment ated specialty integrated programs, such as vascular, incentives could be constructed, ensuring that these spots cardiothoracic and plastic surgery, that have begun to are filled. This would help to streamline and standardize take away these cases from general surgery training. Yet, the approach in training for this type of practice. general surgeons and the surgical education curriculum Just as the era of the cellphone has evolved, the surcontinue to remain in the past by clinging to these areas geon of today looks very different from the one decades of practice. Why are our efforts being focused on the ago. Whether this transition has happened because of past and not toward the future? We residents feeling unprepared shouldn’t fully let go of Just as the era of the cellphone has evolved, the surgeon of today looks for independent practice after those foundational idegeneral surgery training or very different from the one decades ago. Whether this transition has als on which the genfrom a desire among graderal surgeon was built, uates to become a specialist happened because of residents feeling unprepared for independent but if we aren’t careful, is irrelevant—it is a problem practice after general surgery training or from a desire the future will pass us we need to address. Surgiby and leave us with surcal educators must conform among graduates to become a specialist is irrelevant. geons who truly are not to these new standards and prepared for independent stop holding on to the outpractice. dated realities of surgery to The amount of inforimprove the training for the mation needed to be current and future generation processed as a generof surgeons. This new era is al surgeon today is expoupon us and requires our full nentially increasing, and attention to modify surgical innovative procedures training. Implementing a 4+2 are being introduced model would create the flexalmost daily. Although it ibility required for trainees to is unknown whether all experience a wide range of all of these procedures and that surgery has to offer while information will enter also allowing for specialization ■ the armamentarium of to be the focus.

General Surgery Department, Cleveland Clinic, Cleveland

“G

Honorable Mention

AUGUST AUGUST 2020 2020

AUGUST 2020 / GENERAL SURGERY NEWS

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34

RESIDENT WRITING CONTEST

GENERAL SURGERY NEWS / AUGUST 2020

I’m a Stranger Here, Myself

By JOHN P. SKENDELAS, MD Surgical Resident, Montefiore Medical Center, New York City

United States. These entities are in a tremendous position to understand and govern change in surgical education at a national level. This approach allows for the combination of both top-down and bottom-up reconstruction and reframing of surgical education. These data can be augmented further by national resident participation.

Imagine if we asked every surgical trainee: What is the most important change to your residency program and/or hospital system to improve resident satisfaction? What other changes do you propose?

What if these responses were interpreted in the context of demographics, learning style, personality traits, geography and practice setting? Many of these data have already been collected. The responses from a national needs assessment would be immense and powerful.

such as child care or mortgage payments. Independent of this assessment, our hospital recently improved work et us publicly release all of the data from spaces and raised resident salaries. As for the emergency the Accreditation Council for Graduate department, some things may never change.

Medical Education (ACGME) annual surThe availability of such data on a national level veys and assessment of surgical trainees in the would be the first, crucial step to improving resident United States. Incomplete evidence is presented satisfaction within postgraduate surgical education. year after year in the Medscape annual “ResEach trainee would have a voice that can be heard on ident Lifestyle & Happiness Report” and many different levels whether by age, gender, postgrad“National Physician Burnout, Depression uate year, region or hospital setting. Each would have & Suicide Report.” The yearly statistics a unique impact. The success of such an approach has are irrelevant. Many residents and suralready been demonstrated. In Hu et al, an astounding geons were objectively unhappy, and 7,409 residents were surveyed for their study, “Discrimmany are still unhappy. The etiology of ination, Abuse, Harassment, and Burnout in Surgical this disillusionment is the same set of culprits that Residency Training,” published in the New England plagues us all: administrative tasks, work hours, comJournal of Medicine (2019;381:1741-1752). The title is pensation, etc. I groan every time I am made to bear self-explanatory. The results of their study have been witness to this timeless pessimism without recourse. discussed elsewhere, but unsurprisingly reveal more pesIn spite of all the available evidence, a thick cloud of simism without recourse. mystery hangs overhead and we in the comThese “big data” approaches can provide the munity remain estranged from the problems tools to develop top-down (organization-drivfacing us. Fortunately, a solution has already en) and bottom-up (resident-driven) stratebeen proposed by the science fiction author gies. This type of survey has the opportunity Douglas Adams in “The Hitchhiker’s Guide to help gain insight and understanding of what to the Galaxy.” In the story, we are told that residents request from their program, hospital the answer to life, the universe and everything or organization to improve their satisfaction in is the number 42. We and the novel’s protagan evidence-based way. This method implicitonists are alike in that we do not know the ly assesses the etiology of their dissatisfaction right question. but is not the focus. The emphasis is placed on What do we know? Based on the ACGME solutions, offered by the trainees who have the “Data Resource Book” for the academic year most to gain at the program, regional or nation2017-2018, there were 301 accredited general al level. For example, residents who are marsurgery programs with a total of 8,475 active ried with children may be more likely to cite a residents, with a median size of 26 residents need for improved day care programs as a welland mean first year age of 29 years. Residents ness intervention. Alternatively, residents with Every five years, the demographic and associated were predominantly male (58.3%) and white strong neurotic personality traits may cite access challenges of a residency program change. The data (45.8%), compared with women (37.9%) to mental health services or a need for protected and residents of other backgrounds (Asian time off for personal, health care maintenance to help anticipate and address these challenges are or Pacific Islander, 12%; Hispanic/Latino, academic purposes. Residents in urban-based available, yet hidden from the community with the most or 4.6%; Black non-Hispanic, 3.9%; and other programs may cite transportation needs, and so or unknown, 33.4%). The distribution of reson. This would be further extended to a program to gain or lose in the next five years. idents in general surgery and subspecialties director’s perspective when evaluating his or her was disproportionate across the country. The own institution: “My program is composed of District of Columbia was the best represented across all For proof of concept, I attempted to informally ask 50% married residents with neurotic traits in an urban specialties, with 198 residents per 100,000 people. This these questions within my own program. Overall, my academic hospital environment, so we should review day was followed by Connecticut, Massachusetts, Rhode intern colleagues were most concerned about call and care, mental health and transportation policies.”

Island and New York, with between 55 and 73 residents workroom spaces, whereas my junior and chief resident We are all ultimately strangers in some way to the per 100,000 people. On the other end of the spectrum, colleagues cited working with other hospital services same surgical community—strangers who are consisAlaska, Wyoming and Idaho round out the bottom half and financial considerations, respectively. The results tently reevaluating their place in a community that is of the list with about five to seven residents per 100,000 were simple and predictable, yet validating. Interns actively changing to the demands of medicine in the 21st people. The majority of surgical programs were based spend the most time taking care of patients and using century and internally, within the dynamic landscape of in the university or university-affiliated setting (80%), hospital spaces. Junior residents work the most closely generations of surgeons simultaneously coming of age, according to the American Medical Association’s Fel- with the emergency department and other medical ser- maturing and retiring. Every five years, the demographic lowship and Residency Electronic Interactive Database. vices. Chief residents, who are looking to graduate or and associated challenges of a residency program change.

What more should we know? Between these organi- move on to fellowship, invariably recognize the finan- The data to help anticipate and address these challenges zations, there is a treasure trove of information regard- cial burden of medical school debt, inability to effective- are available, yet hidden from the community with the ■ ing residents and their respective programs across the ly invest, and various age-appropriate financial concerns, most to gain or lose in the next five years.

L

Honorable Mention

What I Wish I Knew continued from page 29

The experience also helped him identify what was important to him. Dr. Greene had trained in endoscopy in residency and was excited to bring that skill

to the practice, but local gastroenterologists objected and blocked him from doing so.

“I was devastated that I couldn’t do endoscopy. But this led me, years later, to meet with a group of surgeons who agreed that we should be doing

endoscopy.” That meeting laid the foundation for the Society of American Gastrointestinal and Endoscopic Surgeons.

Looking back, there is one issue that Dr. Greene regrets: tolerating disruptive colleagues. “I would try to

compromise and be the peacemaker— that’s just my personality. But I could have been more proactive with some individuals, which I advise anyone in a leadership position to do. Some individuals tend to hurt others, and we need to deal with that.”

■

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