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Surgery and other invasive therapies are complex interventions, the assessment of which is challenged by factors that depend on operator, team, and setting, such as learning curves, quality variations, and perception of equipoise. We propose recommendations for the assessment of surgery based on a five-stage description of the surgical development process. We also encourage the widespread use of prospective databases and registries. Reports of new techniques should be registered as a professional duty, anonymously if necessary when outcomes are adverse. Case series studies should be replaced by prospective development studies for early technical modifications and by prospective research databases for later pre-trial evaluation. Protocols for these studies should be registered publicly. Statistical process control techniques can be useful in both early and late assessment. Randomised trials should be used whenever possible to investigate efficacy, but adequate pre-trial data are essential to allow power calculations, clarify the definition and indications of the intervention, and develop quality measures. Difficulties in doing randomised clinical trials should be addressed by measures to evaluate learning curves and alleviate equipoise problems. Alternative prospective designs, such as interrupted time series studies, should be used when randomised trials are not feasible. Established procedures should be monitored with prospective databases to analyse outcome variations and to identify late and rare events. Achievement of improved design, conduct, and reporting of surgical research will need concerted action by editors, funders of health care and research, regulatory bodies, and professional societies.

In this study, the authors designed checklists to guide care during operating-room crises and evaluated them in a simulated operating room. The availability of checklists improved adherence to best practices by operating-room teams during simulations of surgical crises. Operating-room crises (e.g., massive hemorrhage and cardiac arrest) are high-risk, stressful events that require rapid and coordinated care in a time-critical setting. The reported incidence may be rare for an individual practitioner, 1 but the aggregate incidence for a hospital with 10,000 operations a year is estimated to be approximately 145 such events annually. 2 These are situations in which the way the team cares for a patient will make the difference between life and death. Failure to effectively manage life-threatening complications in surgical patients has been recognized as the largest source of variation in surgical mortality among hospitals. 3 – 7 Small-scale studies . . .

Presented by the American College of Surgeons and the Alliance for Clinical Trials in Oncology, the first comprehensive, evidence-based examination of cancer surgery techniques as standards distills the well-defined protocols and techniques that are critical to achieve optimal outcomes in a cancer operation. This unique, one of a kind collaboration between the American College of Surgeons and the Alliance for Clinical Trials in Oncology focuses on best practices and state-of-the-art methodologies. Operative Standards for Cancer Surgery clearly describes the surgical activities that occur between skin incision and skin closure that directly affect cancer outcomes.

Background Inattention blindness (IB) can be defined as the failure to perceive an unexpected object when attention is focussed on another object or task. The principal aim of this study was to determine the effect of cognitive load and surgical image guidance on operative IB. Methods Using a randomised control study design, participants were allocated to a high or low cognitive load group and subsequently to one of three augmented reality (AR) image guidance groups (no guidance, wireframe overlay and solid overlay). Randomised participants watched a segment of video from a robotic partial nephrectomy. Those in the high cognitive load groups were asked to keep a count of instrument movements, while those in the low cognitive load groups were only asked to watch the video. Two foreign bodies were visible within the operative scene: a swab, within the periphery of vision; and a suture, in the centre of the operative scene. Once the participants had finished watching the video, they were asked to report whether they had observed a swab or suture. Results The overall level of prompted inattention blindness was 74 and 10 % for the swab and suture, respectively. Significantly higher levels of IB for the swab were seen in the high versus the low cognitive load groups, but not for the suture (8 vs. 47 %, p  < 0.001 and 90 vs. 91 %, p  = 1.000, for swab and suture, respectively). No significant difference was seen between image guidance groups for attention of the swab or suture (29 vs. 20 %, p  = 0.520 and 22 vs. 22 %, p  = 1.000, respectively). Conclusions The overall effect of IB on operative practice appeared to be significant, within the context of this study. When examining for the effects of AR image guidance and cognitive load on IB, only the latter was found to have significance.

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.

IntroductionMedicine relies on innovation to continually improve. However, innovation is potentially risky, and not all innovations are successful. Therefore, it is important to identify innovations prospectively and provide support, to make innovation as safe and effective as possible. The Macquarie Surgical Innovation Identification Tool (MSIIT) is a simple checklist designed as a practical tool for hospitals to identify planned surgical innovations. This project aims to test the usability and pilot the use of the MSIIT in a surgical setting.Methods and analysisThe project will run in two phases at two Australian hospitals, one public and one private. Phase I will involve interviews, focus groups and a survey of hospital administrators and surgical teams to assess the usability and system requirements for the use of the MSIIT. Current practice regarding surgical innovation within participating hospitals will be mapped, and the best implementation strategy for MSIIT completion will be established. Phase II will involve trialling the MSIIT for each surgery within the trial period by various surgical personnel. Follow-up interviews, focus groups and a survey will be conducted with trial participants to collect feedback on their experience of using the MSIIT during the trial period. Comparative data on rates of surgical innovation during the trial period will also be gathered from existing hospital systems and compared to the rates identified by the MSIIT.Ethics and disseminationEthical approval has been obtained. The results of this study will be presented to interested health services and other stakeholders, presented at conferences and published in a peer-reviewed MEDLINE-indexed journal.

Though we've long known that higher surgical volume results in lower postoperative mortality, surgeons are balking at a new “Volume Pledge” campaign. But the biggest problem is that such a pledge can't improve the quality of care at low-volume hospitals. On May 18, 2015, leaders at three hospital systems — Dartmouth–Hitchcock Medical Center, the Johns Hopkins Hospital and Health System, and the University of Michigan Health System — publicly announced a “Take the Volume Pledge” campaign to prevent certain surgical procedures from being performed by their surgeons who perform relatively few of them or at their hospitals where relatively few such procedures are performed. The Pledge, promoted by long-time advocates of quality improvement such as John Birkmeyer and Peter Pronovost, challenges other large health systems to join them in restricting the performance of 10 surgical procedures — including gastrointestinal, cardiovascular, . . .

This analysis of Medicare data suggests that 13% of patients are readmitted to the hospital within 30 days after major surgery. Readmission rates vary across hospitals and correlate with surgical volume and surgical mortality, two measures of surgical quality. Reducing hospital-readmission rates is a priority for both policymakers and clinical leaders. The focus on readmissions has been driven by a belief that reducing the frequency with which patients return to the hospital can both improve care and lower costs. To date, much of the focus has been on readmissions after hospitalization for medical conditions, in which discharge planning and care coordination are often suboptimal. 1 – 4 The Centers for Medicare and Medicaid Services (CMS) plans to include surgical procedures as it expands its readmissions penalty program. 5 Using medical-readmission rates as a measure of hospital quality is controversial. Although hospitals vary . . .

Public reporting of adherence to surgical safety checklists was mandated for all hospitals in Ontario, beginning in July 2010. In this study of administrative data, checklist introduction was not associated with significant reductions in operative mortality or complications. A study published in 2009 showed that implementation of the 19-item World Health Organization (WHO) Surgical Safety Checklist substantially reduced the rate of surgical complications, from 11.0% to 7.0%, and reduced the rate of in-hospital death from 1.5% to 0.8%. 1 The WHO estimated that at least 500,000 deaths per year could be prevented through worldwide implementation of this checklist. 2 This dramatic effect of a relatively simple and accessible intervention resulted in its widespread adoption. In the United Kingdom, a nationwide program was implemented by the National Health Service within weeks after publication of the WHO study, 3 and almost 6000 hospitals . . .

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.