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IntroductionIn carpal tunnel release, it is yet unclear whether a learning curve exists among surgeons. The aim of our study was to investigate if outcome after carpal tunnel release is dependent on surgeon’s experience and to get an impression of the learning curve for this procedure.MethodsA total of 188 CTS patients underwent carpal tunnel release. Patients completed the Boston Carpal Tunnel Questionnaire at baseline and 6–8 months postoperatively together with a six-point scale for perceived improvement.ResultsPatients operated by an experienced resident or certified surgeon reported a favorable outcome more often than patients operated by an inexperienced resident (adjusted OR 3.23 and adjusted OR 3.16, respectively). In addition, a negative association was found between surgeon’s years of experience and postoperative Symptom Severity Scale and Functional Status Scale scores.DiscussionOutcome after carpal tunnel release seems to be dependent on surgical experience, and there is a learning curve in residents.

Objective To examine the effect of surgeon sex on postoperative outcomes of patients undergoing common surgical procedures.Design Population based, retrospective, matched cohort study from 2007 to 2015.Setting Population based cohort of all patients treated in Ontario, Canada.Participants Patients undergoing one of 25 surgical procedures performed by a female surgeon were matched by patient age, patient sex, comorbidity, surgeon volume, surgeon age, and hospital to patients undergoing the same operation by a male surgeon.Interventions Sex of treating surgeon.Main outcome measure The primary outcome was a composite of death, readmission, and complications. We compared outcomes between groups using generalised estimating equations.Results 104 630 patients were treated by 3314 surgeons, 774 female and 2540 male. Before matching, patients treated by female doctors were more likely to be female and younger but had similar comorbidity, income, rurality, and year of surgery. After matching, the groups were comparable. Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days (5810 of 52 315, 11.1%, 95% confidence interval 10.9% to 11.4%) than those treated by male surgeons (6046 of 52 315, 11.6%, 11.3% to 11.8%; adjusted odds ratio 0.96, 0.92 to 0.99, P=0.02). Patients treated by female surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; 0.79 to 0.99, P=0.04), but there was no significant difference in readmissions or complications. Stratified analyses by patient, physician, and hospital characteristics did not significant modify the effect of surgeon sex on outcome. A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.Conclusions After accounting for patient, surgeon, and hospital characteristics, patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality and similar surgical outcomes (length of stay, complications, and readmission), compared with those treated by male surgeons. These findings support the need for further examination of the surgical outcomes and mechanisms related to physicians and the underlying processes and patterns of care to improve mortality, complications, and readmissions for all patients.

Background Several definitions of oncoplastic surgery have been reported in the literature. In an effort to facilitate communication regarding oncoplastic surgery to patients, trainees, and among colleagues, the American Society of Breast Surgeons (ASBrS) aimed to create a consensus definition and classification system for oncoplastic surgery. Methods We performed a comprehensive literature search for oncoplastic surgery definitions using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following this, a consensus definition and classification system was created by the ASBrS. Results Overall, 30 articles defining oncoplastic surgery were identified, with several articles contradicting each other. The ASBrS definition for oncoplastic surgery defines this set of breast-conserving operations using volume displacement and volume replacement principles as: “Breast conservation surgery incorporating an oncologic partial mastectomy with ipsilateral defect repair using volume displacement or volume replacement techniques with contralateral symmetry surgery as appropriate”. Volume displacement is defined as closing the lumpectomy defect and redistributing the resection volume over the preserved breast, and is divided into two levels: level 1 (< 20%) and level 2 (20–50%). Volume replacement includes those situations when volume is added using flaps or implants to correct the partial mastectomy defect. Conclusion The ASBrS oncoplastic surgery definition and classification system provides language to facilitate discussion and teaching of oncoplastic surgery among breast surgeons, trainees, and patients.

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental. This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic.

A significant body of literature has been compiled on the use of TXA in hip and knee arthroplasty but a comprehensive review and analysis of the existing evidence to provide clinical guidance is lacking. [...]the American Association of Hip and Knee Surgeons (AAHKS), the American Academy of Orthopaedic Surgeons (AAOS), the Hip Society, the Knee Society and the American Society of Regional Anesthesia and Pain Medicine (ASRA) have worked together to develop evidence-based guidelines on the use of TXA in primary TJA. Rationale The direct meta-analysis of one moderate-quality and 82 high-quality studies provided significant evidence for the ability of TXA to reduce the risk of blood loss and need for transfusion during the perioperative episode of primary hip and knee arthroplasties.2 Subsequent network meta-analysis supported the blood-sparing properties of TXA.2 Total hip arthroplasty Intravenous and topical TXA have been shown with limited heterogeneity in direct meta-analysis to reduce blood loss.2 Similarly, intravenous and topical TXA were found to reduce the risk of transfusion compared with placebo by 60% and 71%, respectively.2 Network meta-analysis of low-dose intravenous (<20 mg/kg or ≤1 g), high-dose intravenous (≥20 mg/kg or >1 g), high-dose topical (>1.5 g), oral and combined intravenous/topical TXA reduced the risk for blood loss compared with placebo.2 Correspondingly, network meta-analysis demonstrated low-dose intravenous, high-dose intravenous, high-dose topical, low-dose topical and combined intravenous/topical TXA to significantly reduce the risk of transfusion.2 Due to a lack of studies directly comparing oral TXA with placebo, no conclusions could be derived in the direct meta-analysis.2 Network meta-analysis was performed to provide an indirect comparison of oral TXA, which demonstrated significantly reduced blood loss compared with placebo.2 Although oral TXA was shown to be equivalent regarding risk of transfusion to all other formulations of TXA in the network meta-analysis, oral TXA did not reduce the risk of transfusion compared with placebo. Rationale The direct meta-analysis of 31 high-quality studies provided no evidence to favor any specific method of TXA to reduce the risk of blood loss and need for transfusion during the perioperative episode of primary hip and knee arthroplasties.2 Subsequent network meta-analysis included a more expansive comparison between the methods of TXA administration with no evidence to clearly support a superior method of administration.2 Total hip arthroplasty Intravenous and topical TXA have been compared together in multiple randomized clinical trials, which through direct meta-analysis showed no difference in the risk of transfusion.2 Network meta-analysis provided the opportunity to perform direct and indirect comparisons between low-dose intravenous (<20 mg/kg or ≤1 g), high-dose intravenous (≥20 mg/kg or >1 g), low-dose topical (≤1.5 g), high-dose topical (>1.5 g), oral and combined intravenous/topical TXA.2 In terms of the ability to reduce blood loss, no method of TXA administration was found to provide a significantly different outcome.2 Similar results in the network meta-analysis were observed for risk of transfusion with the exception that a combination of intravenous and topical TXA was equivalent to oral TXA but superior to low-dose intravenous, high-dose intravenous, low-dose topical and high-dose topical TXA.2 However, the inconsistent result regarding combined intravenous/topical TXA likely represents bias from a limited number of studies and not superiority to other methods of TXA administration. Total knee arthroplasty Direct comparisons were performed between intravenous TXA and topical, oral or combined intravenous/topical TXA, which found no difference in the risk of transfusion.2 Similar to the network meta-analysis of THA, direct and indirect comparisons were performed between low-dose intravenous, high-dose intravenous, low-dose topical, high-dose topical and oral TXA as well as combinations of intravenous/topical and intravenous/oral TXA that resulted in no difference in their blood-sparing properties.2 The significant differences between methods of TXA administration were observed in respect to the risk of transfusion being higher for low-dose intravenous TXA compared with high-dose intravenous or combined intravenous/topical TXA, which could represent a dose response or the limited number of studies.2 Guideline question 3 For patients undergoing primary TJA, does the dose amount of intravenous or topical TXA affect the risk of transfusion and/or reduction in blood loss?

Purpose With the global epidemic of obesity, the importance of metabolic and bariatric surgery (MBS) is greater than ever before. Performing these surgeries requires academic training and the completion of a dedicated fellowship training program. This study aimed to develop guidelines based on expert consensus using a modified Delphi method to create the criteria for metabolic and bariatric surgeons that must be mastered before obtaining privileges to perform MBS. Methods Eighty-nine recognized MBS surgeons from 42 countries participated in the Modified Delphi consensus to vote on 30 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. Results Consensus was reached on 29 out of 30 statements. Most experts agreed that before getting privileges to perform MBS, surgeons must hold a general surgery degree and complete or have completed a dedicated fellowship training program. The experts agreed that the learning curves for the various operative procedures are approximately 25–50 operations for the LSG, 50–75 for the OAGB, and 75–100 for the RYGB. 93.1% of experts agreed that MBS surgeons should diligently record patients’ data in their National or Global database. Conclusion MBS surgeons should have a degree in general surgery and have been enrolled in a dedicated fellowship training program with a structured curriculum. The learning curve of MBS procedures is procedure dependent. MBS surgeons must demonstrate proficiency in managing postoperative complications, collaborate within a multidisciplinary team, commit to a minimum 2-year patient follow-up, and actively engage in national and international MBS societies. Graphical Abstract

AbstractObjectiveTo investigate whether patients’ mortality differs according to the age and sex of surgeons.DesignObservational study.SettingUS acute care hospitals.Participants100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014.Main outcome measureOperative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients’ and surgeons’ characteristics and indicator variables for hospitals.Results892 187 patients who were treated by 45 826 surgeons were included. Patients’ mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients’ mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality.ConclusionUsing national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.

When evaluating surgeons in the operating room, experienced physicians must rely on live or recorded video to assess the surgeon's technical performance, an approach prone to subjectivity and error. Owing to the large number of surgical procedures performed daily, it is infeasible to review every procedure; therefore, there is a tremendous loss of invaluable performance data that would otherwise be useful for improving surgical safety. To evaluate a framework for assessing surgical video clips by categorizing them based on the surgical step being performed and the level of the surgeon's competence. This quality improvement study assessed 103 video clips of 8 surgeons of various levels performing knot tying, suturing, and needle passing from the Johns Hopkins University-Intuitive Surgical Gesture and Skill Assessment Working Set. Data were collected before 2015, and data analysis took place from March to July 2019. Deep learning models were trained to estimate categorical outputs such as performance level (ie, novice, intermediate, and expert) and surgical actions (ie, knot tying, suturing, and needle passing). The efficacy of these models was measured using precision, recall, and model accuracy. The provided architectures achieved accuracy in surgical action and performance calculation tasks using only video input. The embedding representation had a mean (root mean square error [RMSE]) precision of 1.00 (0) for suturing, 0.99 (0.01) for knot tying, and 0.91 (0.11) for needle passing, resulting in a mean (RMSE) precision of 0.97 (0.01). Its mean (RMSE) recall was 0.94 (0.08) for suturing, 1.00 (0) for knot tying, and 0.99 (0.01) for needle passing, resulting in a mean (RMSE) recall of 0.98 (0.01). It also estimated scores on the Objected Structured Assessment of Technical Skill Global Rating Scale categories, with a mean (RMSE) precision of 0.85 (0.09) for novice level, 0.67 (0.07) for intermediate level, and 0.79 (0.12) for expert level, resulting in a mean (RMSE) precision of 0.77 (0.04). Its mean (RMSE) recall was 0.85 (0.05) for novice level, 0.69 (0.14) for intermediate level, and 0.80 (0.13) for expert level, resulting in a mean (RMSE) recall of 0.78 (0.03). The proposed models and the accompanying results illustrate that deep machine learning can identify associations in surgical video clips. These are the first steps to creating a feedback mechanism for surgeons that would allow them to learn from their experiences and refine their skills.

Background Distractions during surgical procedures have been linked to medical error and team inefficiency. This systematic review identifies the most common and most significant forms of distraction in order to devise guidelines for mitigating the effects of distractions in the OR. Methods In January 2015, a PubMed and Google Scholar search yielded 963 articles, of which 17 (2 %) either directly observed the occurrence of distractions in operating rooms or conducted a laboratory experiment to determine the effect of distraction on surgical performance. Results Observational studies indicated that movement and case-irrelevant conversation were the most frequently occurring distractions, but equipment and procedural distractions were the most severe. Laboratory studies indicated that (1) auditory and mental distractions can significantly impact surgical performance, but visual distractions do not incur the same level of effects; (2) task difficulty has an interaction effect with distractions; and (3) inexperienced subjects reduce their speed when faced with distractions, while experienced subjects did not. Conclusion This systematic review suggests that operating room protocols should ensure that distractions from intermittent auditory and mental distractions are significantly reduced. In addition, surgical residents would benefit from training for intermittent auditory and mental distractions in order to develop automaticity and high skill performance during distractions, particularly during more difficult surgical tasks. It is unclear as to whether training should be done in the presence of distractions or distractions should only be used for post-training testing of levels of automaticity.

BackgroundPancreaticoduodenectomy (PD) is one of the most technically difficult abdominal operations. Recent advances have allowed surgeons to attempt PD using minimally invasive surgery techniques. This retrospective study aimed to analyze the learning curve of a single surgeon who had carried out his first 100 robot-assisted laparoscopic pancreaticoduodenectomy (RPD) in a high-volume pancreatic center.MethodsThe data on consecutive patients who underwent RPD for malignant or benign pathologies were prospectively collected and retrospectively analyzed. The data included the demographic data, operative time, estimated blood loss, postoperative length of hospital stay, morbidity rate, mortality rate, and final pathological results. The cumulative sum (CUSUM) analysis was used to identify the inflexion points which corresponded to the learning curve.ResultsBetween 2012 and 2016, 100 patients underwent RPD by a single surgeon. From the CUSUM operation time (CUSUM OT) learning curve, two distinct phases of the learning process were identified (early 40 patients and late 60 patients). The operation time (mean, 418 min vs. 317 min), hospital stay (mean, 22 days vs. 15 days), and estimated blood loss (mean, 227 ml vs. 134 ml) were significantly lower after the first 40 patients (P < 0.05). The pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, and reoperation rates also decreased in the late 60 patients group (P < 0.05). Non-significant reductions were observed in the incidences of major (Clavien–Dindo Grade II or higher) morbidity, postoperative death, bile leakage, gastric fistula, wound infection, and open conversion.ConclusionsRPD was technically feasible and safe in selected patients. The learning curve was completed after 40 RPD. Further studies are required to confirm the long-term oncological outcomes of RPD.