Two-trocar appendectomy in children – description of technique and comparison with conventional laparoscopic appendectomy

Background: The aim of the study was to describe the technique of two-trocar laparoscopic appendectomy and compare the outcome between two- and three-trocar techniques in children. Methods: All children who underwent laparoscopic surgery for suspected appendicitis from 2006 to 2014 in a center for pediatric surgery were included in the study. Converted surgeries and patients with appendiceal abscess or concomitant intestinal obstruction were excluded. A total of 259 children underwent appendectomy with either two (35 %) or three (65 %) laparoscopic trocars according to the surgeons' preference and intraoperative judgment. Patient demographics, clinical symptoms, surgery characteristics, and complications were reviewed. Results: The mean age of the children was 10.4 years (range, 1-14 years). The mean follow-up time was 41.2 months (SD ± 29.2). No significant differences in age, gender, weight, or signs and symptoms were found between the two- and three-trocar groups. The mean surgery time was significantly shorter in the two-trocar group (47 min) than in the three-trocar group (66 min; p < 0.001). The rates of surgical complications were 2 % vs. 4 %, (p = 0.501), and the rates of postoperative complications were 0 % vs. 5 % (p = 0.054), in the two- and three-trocar groups. The overall incidence of postoperative wound infection was low (<1 %) and did not differ between groups. Conclusions: Two-trocar laparoscopic appendectomy seems to be a safe and feasible technique with a low rate of postoperative wound infections. The present findings demonstrate that when the two-trocar technique could be applied, it is a good complement to the conventional three-trocar technique

Three-Dimensional vs Two-Dimensional Minimally Invasive Surgery. A comparison of the visual work load and surgical outcomes

BACKGROUND Three-dimensional (3D) imaging, a recent technical innovation in laparoscopic surgery, has been introduced to enhance depth perception and facilitate operations. The clear benefit of the 3D laparoscopy has never been tested. Some concerns emerged regarding the possible negative effects over the visual system in those surgeons who performed 3D surgery every day. 3D laparoscopy has been validated both in “in-vitro” and “in-vivo” (clinical) settings. All survey done in laparoscopic simulator comparing surgical exercise (suturing, peg transfer, cutting) performed with 2D or 3D system reported better results in the second group, regardless the surgeon experience. Less data is disposable in the clinical setting, but with same conclusions. The use of 3D technology needs passive or active polarized glasses. Optometric tests, objective exams (RMN or EEG) and subjective questionnaires have been widely used to evaluate the alterations in the visual system utilizing the 3D technology. Each test concluded that 3D technology causes alteration in the EEG waves, but how long these alterations last is still unknown. AIM The aim of this study was to evaluate the possible benefit of using the 3D technology in terms of surgical outcomes (study 1) and to evaluate the alterations over the visual system operating in 3D laparoscopy (study 2). MATERIALS AND METHODS The study was a single-center prospective observational clinical trial, divided in two sub-study with a single patients-population. Participants included patients aged 18 years old and above, eligible for colorectal resections for neoplastic or inflammatory diseases. Four experienced surgeons in colorectal and laparoscopic surgery participated in the study. Each surgeon followed the standard laparoscopic surgical rules performing the different type of colorectal resection, regardless the study subgroup. Data were collected at the pre-operative clinic, during surgery, during the hospitalizations and at the short term follow-up (30th days). For each study, there was a primary endpoint: 1. Primary endpoint for Study 1: incidence of Clavien grade 3, 4 and 5 postsurgical complications in patients undergone 3D colorectal resection; 2. Primary endpoint for Study 2: to grade the visual work load of surgeons operating with 3D screens and glasses. At the end of each procedure (2D or 3D) the first surgeon had to fill in two different subjective questionnaire (the NASA task load index questionnaire and the Simulator Sickness questionnaire) to grade the visual sickness felt during the operation. RESULTS From January 2015 to September 2017, 313 patients were enrolled in the study: 82 in the 2D group, 231 in the 3D group. STUDY 1: Colorectal cancer was the main indication for surgery (n 235, 75.1%), followed by colonic diverticulosis, benign polyposis and inflammatory bowel diseases (IBD), respectively 43 (13.8 %), 25 (7.9 %) and 10 (3.2 %). Age, sex, ASA score were comparable between the two groups. The median operative time showed no statistically significant difference between the 3D and 2D groups (p 0.611). Less drains were positioned at the end of the 3D operations comparing with 2D procedures (p 0.013). The stapled anastomosis was the most frequent performed over other techniques. The other intra-operative findings showed no significant difference between the two study groups. The median hospitalization and the reoperation rate showed no difference between the two groups. STUDY 2: The statistical analysis done over all 313 cases divided in 2D and 3D did not reveled significant difference of the visual work scored by the NASA TLX. Data emerging from the SSQ questionnaire reveled no case of moderate or severe symptoms in both groups. CONCLUSIONS 3D laparoscopic surgery had the same postoperative results of the 2D standard laparoscopy. The more frequent intra-abdominal anastomosis in the 3D group might suggest a more safeness felt by the surgeon using the new technology. The NASA TLX and the SSQ questionnaire did not reveled significant difference of the visual work between 2D and 3D vision

Low value care in surgery

Background Value has been defined as the ratio of quality outcomes to cost. Perfect value would represent infinitely beneficial outcomes associated with minimal costs. Of interest to the present study are interventions where outcomes are minimal, and costs may be high as they may provide an opportunity for disinvestment, improving the overall value of care whilst providing efficiency gains. Methods A Scoping Narrative Review was performed in order to understand incumbent approaches towards dealing with low value care. International lessons from different processes were identified and encompassed into a conceptual logic orientated framework for de-adoption. To identify low value care in surgery a Systematic review of peer reviewed high-level literature was performed to identify candidate interventions for de-adoption. Subsequently a granular assessment of the behaviour of passive de-adoption was performed through a retrospective longitudinal observational study based upon administrative hospital data. Results A comprehensive conceptual model that takes an integrated approach to de-adoption was assembled from lessons learnt when dealing with low value care previously. It identified three stages in the de-adoption cycle which are necessary for success: identification, implementation and re-evaluation. Each process should be performed at multiple planes: national (macro), local (meso) and provider / patient (micro) levels in order to have a holistic effect. The identification of low value interventions may be from exploring peer reviewed literature, as demonstrated from the systematic review or exploring geographical variation of care. Said review identified 71 low value procedures, of which 5 interventions which carried the highest economic burden were postulated to cost the health system £135 million per annum. Subsequent granular review identified that passive levers have not resulted in de-adoption of a surgical low value interventions – e.g. delayed cholecystectomy. This is due to the presence of exnovator providers whom are concurrently de-adopting innovative interventions as other providers are adopting them. Conclusions Low value care represents a significant burden in the current health service. This thesis has evaluated its incidence and economic burden in general surgery. Service transformation is necessary and may be achieved through the holistic integrated approach recommended here. Policy makers have already sought this novel information and encompassed it into national policy, with the objective of achieving higher value care through effective de-adoption.Open Acces

Contemporary Topics in Graduate Medical Education

Graduate medical education (GME) is a continually evolving, highly dynamic area within the complex fabric of the modern health-care environment. Given the rapidly changing regulatory, financial, scientific and technical aspects of GME, many institutions and programs face daily challenges of "keeping up" with the most recent developments within this ever-more-sophisticated operational environment. Organizational excellence is a requirement for the seamless functioning of GME programs, especially when one consider the multiple disciplines and stakeholders involved. The goal of the current book cycle, titled Contemporary Topics in Graduate Medical Education, beginning with this inaugural tome, is to provide GME professionals with a practical and readily applicable set of reference materials. More than 20 distinguished authors from some of the top teaching institutions in the US, touch upon some of the most relevant, contemporary, and at times controversial topics, including provider burnout, gender equality issues, trainee wellness, scholarly activities and requirements, and many other theoretical and practical considerations. We hope that the reader will find this book to be a valuable and high quality resource of a broad range of GME-related topics. It is the Editors' goal to create a multi-tome platform that will become the definitive go-to reference for professionals navigating the complex landscape of modern graduate medical education

The Effect of Public Policy on Health Service Providers

Chapter 1 Low-income, publicly insured admissions historically cost more to treat than the average patient. To ensure that hospitals are reimbursed an adequate amount for care of indigent populations, Medicare reimburses hospitals an additional percentage amount according to federally set financial schedule. The reimbursement cutoff is discrete: at fifteen percent of a disproportionate patient percentage, a hospital is reimbursed an extra 2.5 percent of the standard prospective payment rate. I extend a simple model of hospital quality as a function of insurance reimbursement increases to determine that under certain circumstances there exists a positive relationship between quality and reimbursement. I use Hospital Consumer Assessment of Healthcare Providers and Systems data to analyze hospital ratings around the fifteen percent disproportionate patient percentage cutoff and find that on average, hospital ratings increase by six percentage points. When a subsample of non-profit hospitals is analyzed, hospital ratings increase by an average of 6.5 percentage points, primarily driven by patient facility cleanliness and medical provider communication ratings. Chapter 2 The Center for Medicare and Medicaid Services (CMS) created the Hospital Compare Program in 2003 to increase transparency between health care providers and consumers. Implemented in 2005, this transparency consists of hospitals\u27 collecting and making publicly available a set of hospital quality score measures. The CMS induced participation by financially penalizing hospitals that did not publicly report a specific subset of these measures (called starter measures). Three years into the program, the penalty for non-reporting both the starter measures and other ( non-starter ) measures was increased. I use a difference-in-differences methodology to analyze the effect of the increased CMS penalty on the likelihood that a hospital publicly reported its starter and non-starter measure scores. I find that the penalty had an economically and statistically insignificant effect on the probability that a hospital publicly reported its starter scores but a statistically significant eight percent effect (p \u3c 0.01) on whether it reported its non-starter scores. These findings are robust to a series of alternative empirical specifications. Chapter 3 In 2006, Massachusetts passed a health care reform which required individuals to purchase health insurance and provided subsidized health insurance to the poor. The reform greatly increased the proportion of the state population that was insured. In this study we use a large data set of private health insurance claims to analyze the effect of the increase in the number of insured on physician reimbursement. We find that reimbursement for well-infant visits rose by approximately 4 percent during the reform implementation period, but the increase did not persist. Reimbursement for well-adult visits and appendectomies remained unchanged. Triple difference estimates using appendectomies (for which demand is extremely inelastic) as an additional control group show a 2 percent rise in well-infant visit reimbursement during the implementation period and no effect afterwards or on well-adult visit reimbursement. Estimates imply a temporary increase in the cost of health services with relatively elastic demand following a large scale insurance mandate, such as the Affordable Care Act