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ImportanceCharacteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education.ObjectiveTo determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident.Design, Setting, and ParticipantsThe multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores.Main Outcome and MeasuresSurgical educators’ rankings of general surgery residency graduates’ overall performance.ResultsFifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P r = 0.726; P r = 0.715; P r = 0.707; P Conclusions and RelevanceAll individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

Background Consensus on the best surgical strategy for the management of synchronous colorectal liver metastases (sCRLM) has not been achieved. This study aimed to assess the attitudes of surgeons involved in the treatment of sCRLM. Methods Surveys designed for colorectal, hepato-pancreato-biliary (HPB), and general surgeons were disseminated through representative societies. Subgroup analyses were performed to compare responses between specialties and continents. Results Overall, 270 surgeons (57 colorectal, 100 HPB and 113 general surgeons) responded. Specialist surgeons more frequently utilized minimally invasive surgery (MIS) than general surgeons for colon (94.8% vs. 71.7%, p p p = 0.005). In patients with an asymptomatic primary, the liver-first two-stage approach was preferred in most respondents’ centres (59.3%), while the colorectal-first approach was preferred in Oceania (83.3%) and Asia (63.4%). A substantial proportion of the respondents (72.6%) had personal experience with minimally invasive simultaneous resections, and an expanding role for this procedure was foreseen (92.6%), while more evidence was desired (89.6%). Respondents were more reluctant to combine a hepatectomy with low anterior (76.3%) and abdominoperineal resections (73.3%), compared to right (94.4%) and left hemicolectomies (90.7%). Colorectal surgeons were less inclined to combine right or left hemicolectomies with a major hepatectomy than HPB and general surgeons (right: 22.8% vs. 50% and 44.2%, p = 0.008; left: 14% vs. 34% and 35.4%, p = 0.002, respectively). Conclusion The clinical practices and viewpoints on the management of sCRLM differ between continents, and between and within surgical specialties. However, there appears to be consensus on a growing role for MIS and a need for evidence-based input. Graphical abstract

Background: Major bile duct injuries (BDIs) are hazardous complications after laparoscopic cholecystectomy (0.4%-0.6% of all laparoscopic cholecystectomies) [1, 2-4]. Major BDIs usually require surgery, ideally either within one week or after 3 three months after index surgery [1]. We describe the case of iatrogenic transection of the common bile duct (CBD) complicated by a complex full midline abdominal evisceration presented on day 12 after emergency laparotomy for biliary peritonitis. Case Presentation: A 65-year-old male underwent laparoscopic cholecystectomy in a district general hospital and was discharged on the same day, following apparently uneventful surgery. He, however, re-presented two days later with biliary peritonitis when emergency ERCP showed full CBD transection. The local surgical team performed midline exploratory laparotomy, washout, and external drainage aside the leaking CBD and referred the case to our tertiary HPB service. While awaiting transfer (due to bed shortage), full wound dehiscence occurred. On transfer arrival at our HPB service on postoperative day 11, the patient presented extensive evisceration with loss of domain and persisting high-volume biliary spillage aside bowels. Following assessment and fast literature review, we considered operation undeferrable and planned multi-stage surgeries, including primary Roux-en-Y hepaticojejunostomy (HJ) and progressive abdominal wall closure in multiple sessions under general anaesthesia, aided by vacuum-assisted wound closure and intraperitoneally mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh. Discussion and Conclusion: The complexity of our case lies in the coexistence of 2-weeks biliary peritonitis following early BDI with massive midline evisceration, in combination, both representing over 40% mortality risk, requiring immediate, simultaneous repair. Roux-en-Y HJ and VAWCM have proven safe and effective.

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

The operative technique for Spigelian hernia (SH) continues to evolve over the last few decades. The primary endpoint of this systematic review was to evaluate the evolution of surgical technique for the management of SH in adults, and to identify the optimum technique for easy identification of anatomical landmarks. The secondary outcome was to evaluate the operative management of bilateral SH. A systematic search using Cochrane, Medline, and Google Scholar databases was performed to identify all studies from 1989 to 2019 investigating the management of SH. Of 535 articles identified, 29 studies reporting on 619 patients (389 open repair and 230 laparoscopic repair) were included, out of which 25 studies (469 patients) described complication and recurrence rate. Five additional studies reporting on five patients with bilateral SH were identified for a total of 19 cases (3.1%) of bilateral SH. There has been a gradual transition from open to laparoscopic SH repair over the last three decades. Overall complication and recurrence rates after SH repair were 5.5% and 2.8% respectively, with higher rates in open repair (complication 7.7% and recurrence 4.2%). The laparoscopic transabdominal preperitoneal repair (TAPP) has the lowest recurrence and complication rate reported in the literature. The choice of SH repair should be based on the need for abdominal wall reconstruction, any associated intra-abdominal pathology, and the experience of the surgeon. Laparoscopic TAPP with mesh appears to have the lowest complication and recurrence rate.

Tocilizumab, a monoclonal antiinterluekin-6 receptor antibody, has been empirically used in the treatment of cytokine release syndrome associated with severe coronavirus disease 2019 infections. The efficacy and safety of these medications for these patients is unknown. The purpose of this report was to present a case of acute large bowel perforation in a morbidly obese patient with coronavirus disease 2019 pneumonia who received empiric Tocilizumab. This case report analyzes the risks of acute large bowel perforation after using this medication empirically and discusses the appropriate management of this adverse event.

This chapter discusses technical aspects of laparoscopic unroofing of hepatic cyst, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic distal pancreatectomy with splenectomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of open distal pancreatectomy with splenectomy, including instrumentation and equipment, patient positioning, and surgical steps. The authors also offer pearls and pitfalls.

Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution’s laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

Desmoplastic small round cell tumor (DSRCT) is a rare mesenchymal tumor usually affecting young patients. Local dissemination is common, and liver is the most common site for extraperitoneal metastases. Multimodal management has been shown to be the most effective treatment. Some authors consider liver metastases especially bi-lobar disease as a contraindication for surgical resection. We present a case of a DSRCT with bi-lobar metastases in an adult patient who underwent multi-modal management along with hepatectomy. A 51-year-old man was found to have a large intraperitoneal mass with bi-lobar liver metastases during work up for new onset reflux and abdominal pain. Biopsy confirmed it as DSRCT. The patient was treated with multi-modal therapy including cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), two-stage hepatectomy (TSHP) combined with (90Y) Yittrium-90 radioembolization of the right hepatic lobe and systemic chemotherapy. The patient had a right-sided pleural empyema one month after the surgery for which he required right-sided video-assisted thoracoscopy and decortication. He remains disease free at 2 years follow-up. DSRCT with bi-lobar liver metastases are best managed with multimodal therapy. TSHP seems to be a feasible and safe option in selected cases, with a potentially good outcome.

Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot’s triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents. Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot’s triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy. Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001). IOIFC increases the visualization of Calot’s triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

BACKGROUND: Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. METHODS: Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. RESULTS: The average length of the surgery was 125 minutes (range, 51‐304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1‐14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. CONCLUSIONS: Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.

Laparoscopic sleeve gastrectomy is a viable option that is becoming common in the management of morbid obesity. The aim of this study was to examine the effectiveness and safety of laparoscopic sleeve gastrectomy as a primary step for rapid weight loss in patients who required a second non-bariatric procedure.After Internal Review Board approval and with adherence to HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all patients who underwent laparoscopic sleeve gastrectomy as a primary procedure for a second non-bariatric operation from November 2004 to September 2008 at the Bariatric and Metabolic Institute at Cleveland Clinic Florida. The data was reviewed for age, gender, percentage of excess weight loss (%EWL), preoperative and postoperative body mass index (BMI), morbidity, and mortality. Mean follow-up time was 7 months (range, 2 weeks-12 months).Laparoscopic sleeve gastrectomy was performed in 18 patients who needed a second non-bariatric procedure such as knee replacement surgery, recurrent incisional hernia repair, laminectomy of the lumbar spine, kidney transplant, anterior cervical discectomy, and nephrectomy. Mean preoperative weight and BMI were 124.9 kg (range, 95.5-172.3 kg) and 44.87 kg/m2 (range, 33.36-58.87 kg/m2), respectively. Mean postoperative weight and BMI were 99.2 kg (range, 68.2-132.2 kg) and 35.79 kg/m2 (range, 23.46-48.97 kg/m2), respectively. There were no conversions to an open procedure in this series. There was no morbidity or mortality in this series.In this small group, laparoscopic sleeve gastrectomy appears to be an effective and safe first surgical approach for rapid weight loss in high-risk patients that require a second non-bariatric procedure.

Bezoar is a rare cause of small bowel obstruction after Roux-en-Y gastric bypass (RYGB). We report the case of a 34-year-old man who developed small bowel obstruction secondary to a phytobezoar at the jejunojejunal anastomosis, 5½ years after the patient underwent RYGB for morbid obesity. The phytobezoar developed in the background of recurring abdominal pain. Imaging studies suggested complete obstruction of the alimentary limb. Laparoscopic exploration demonstrated complete obstruction of the alimentary and biliopancreatic limb. Patient had successful treatment with laparoscopic enterototomy. Six months after the laparoscopic removal of phytobezoar, patient remained asymptomatic. Phytobezoar formation must be considered in the differential diagnosis when postgastric bypass patients present late with obstructive symptoms. We believe that this is the first report of a phytobezoar obstructing at the jejunojejunal anastomosis after RYGB.

Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases. A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used. IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p

Identification of adrenal glands from the surrounding structures during laparoscopic surgery can be challenging especially in obese individuals. This can increase the chances for hemorrhage and conversion to open surgery. We present the first report of fluorescent infrared visualization of the adrenal glands in a large animal model. Five adult Yorkshire pigs were utilized for the study, in compliance with the animal study regulations. After an intravenous bolus administration of 3 mL of indocyanine green (ICG), visualization was performed with a xenon/infrared light source and a laparoscope with a charge-coupled filter device. Activation of the device was done with a foot pedal. Images were analyzed using histogram software and the difference of enhancement was statistically analyzed using unpaired two-tailed t test. The right adrenal glands were visualized in all five animals immediately after administering ICG. Fluorescence facilitated demarcation of adrenal gland tissue from surrounding adipose tissue. Peritoneum and fat was visualized in black color. Adrenal enhancement lasted for 4 h in all cases. The mean value for adrenal fluorescence using histogram count was 71.75 pixels, and for adrenal xenon was 168.87 pixels (p = 0.0002; 95 % CI −130.93 to −0.63). The mean value for fat fluorescence using histogram count was 5.54 pixels and fat xenon was 187.15 pixels (p = 0.0001; 95 % CI −199.39 to −163.82). Although there was no significant difference between adrenal and fat enhancement with xenon light (p = 0.24; 95 % CI −15.53 to 52.09), the difference became significant between adrenal and fat fluorescence (p = 0.0001; 95 % CI 48.51–83.9). Fluorescence imaging appears to be a feasible and easy method to differentiate adrenal glands from the surrounding tissue in a large animal model. Further studies are necessary to investigate the real application of this method during laparoscopic adrenalectomy in humans.

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

The Rhodococcus species rarely cause musculoskeletal infections, with only two cases reported in the literature. We report the case of a 53-year-old woman who had an infection develop after first metatarsophalangeal joint fusion. A year after surgery, she continued to have pain and swelling with nonunion. She underwent revision of the arthrodesis and tissue samples from surgery revealed Rhodococcus erythropolis. The patient's symptoms improved with oral antibiotics. One year after the revision surgery, the fusion had united. We believe this is the first report of a case of a musculoskeletal infection caused by Rhodococcus erythropolis.

Background The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States. Methods A retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities. Results Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m 2 , respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m 2 , respectively. The median length of follow-up was 12 months (range 1–66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively. Conclusion Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.