Publications by authors named "Dimitrios Stefanidis"

202 Publications

Guidelines for the performance of minimally invasive splenectomy.

Surg Endosc 2021 Sep 27. Epub 2021 Sep 27.

Department of Surgery, Indiana University School of Medicine, Indianapolis, USA.

Background: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear.

Objective: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS.

Methods: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations.

Results: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions.

Conclusions: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.
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http://dx.doi.org/10.1007/s00464-021-08741-2DOI Listing
September 2021

Postoperative 4-Year Outcomes in Septuagenarians Following Bariatric Surgery.

Obes Surg 2021 Sep 3. Epub 2021 Sep 3.

Department of Surgery, Indiana University School of Medicine Indiana, Indianapolis, IN, USA.

Background: Bariatric surgery is the most effective treatment for obesity; however, its utilization in older patients remains low. There is a dearth of literature on long-term effectiveness and safety of bariatric surgery in septuagenarian patients. The aim of this study was to compare the short- and long-term outcomes of bariatric surgery in this population.

Methods: Patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) at our institution between 2011 and 2015 were included. Patients were divided into two age groups: < 70 and ≥ 70 years. Outcomes included postoperative hospital length of stay (LOS), 30-day complications, up to 4-year complications, 90-day mortality, comorbidity resolution, and 4-year weight loss (BMI change-ΔΒΜΙ). The groups were also compared using multivariable analyses adjusting for potential confounders (gender, preoperative BMI, and type of procedure).

Results: Twenty-nine septuagenarians who underwent 21 LRYGB (72.4%) and 8 LSG (27.6%) were compared to 1016 patients aged < 70 years operated on during the same time period. Additionally, following the multivariable analyses, the septuagenarians had higher LOS (3 vs 2.3 days, p = 0.01), 4-year complications (38% vs 23%, p = 0.012), and less comorbidities' resolution but similar 4-year ΔBMI (- 8.6 vs - 10, p = 0.421), and 30-day complications (10% vs 6%, p = 0.316).

Conclusion: Bariatric surgery in carefully selected septuagenarians can be accomplished with acceptable safety and comparable postoperative weight loss at 4 years. Surgeons may consider broadening their selection criteria to include this patient subgroup but may allow the patients to reap its benefits if offered earlier in life.
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http://dx.doi.org/10.1007/s11695-021-05694-2DOI Listing
September 2021

Comment on: Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population-based study.

Surg Obes Relat Dis 2021 Oct 8;17(10):1750-1751. Epub 2021 Jul 8.

Department of Surgery, Section of Bariatric and Minimally Invasive Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1016/j.soard.2021.07.004DOI Listing
October 2021

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training.

Eur Urol Open Sci 2020 Dec 6;22:23-33. Epub 2020 Nov 6.

Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.

Context: The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence Acquisition: This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence Synthesis: There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions: Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient Summary: Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.
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http://dx.doi.org/10.1016/j.euros.2020.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317899PMC
December 2020

Does the advanced training in laparoscopic suturing enhance laparoscopic suturing skill beyond fundamentals of laparoscopic surgery?

Surgery 2021 Oct 28;170(4):1125-1130. Epub 2021 Jul 28.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address:

Background: Laparoscopic suturing is associated with a steep learning curve. Hence, many general surgery graduate residents entering fellowship have reportedly not been able to proficiently suture laparoscopically despite achieving Fundamentals of Laparoscopic Surgery certification. To address this deficiency, the Advanced Training in Laparoscopic Suturing curriculum was developed. This study aimed to compare the effectiveness of the Advanced Training in Laparoscopic Suturing curriculum in improving laparoscopic suturing skills compared with Fundamentals of Laparoscopic Surgery training.

Methods: Novices were enrolled in a prospective randomized controlled study. All novices followed proficiency-based training on Fundamentals of Laparoscopic Surgery peg-transfer and intracorporeal suturing. Students were then stratified based on their peg-transfer performance and randomized into an Advanced Training in Laparoscopic Suturing or Fundamentals of Laparoscopic Surgery group. The Advanced Training in Laparoscopic Suturing group trained on 3 of the 6 Advanced Training in Laparoscopic Suturing tasks (needle handling, offset forehand suturing, confined space suturing), while the Fundamentals of Laparoscopic Surgery group was assigned more stringent suturing performance goals. Each group trained for an additional 6 hours, after which the laparoscopic suturing performance of the 2 groups was compared on a Nissen fundoplication porcine model.

Results: Thirty-nine medical students were enrolled in the study; 17 (11 males and 6 females) completed the study protocol (44%). Controlling for confounders including the student suturing performance at the end of stage-1 training, the Advanced Training in Laparoscopic Suturing group at the porcine model was significantly faster/safer (coefficient = 102.7, P = .037), and more skilled (coefficient = 19.1, P = .048) compared with the Fundamentals of Laparoscopic Surgery group.

Conclusion: Compared with Fundamentals of Laparoscopic Surgery training alone the Advanced Training in Laparoscopic Suturing curriculum further enhances the laparoscopic suturing skill of novices. These findings support incorporating Advanced Training in Laparoscopic Suturing into existing skills curricula.
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http://dx.doi.org/10.1016/j.surg.2021.06.041DOI Listing
October 2021

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 Sep 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

Guideline Assessment Project II: statistical calibration informed the development of an AGREE II extension for surgical guidelines.

Surg Endosc 2021 Aug 22;35(8):4061-4068. Epub 2021 Jun 22.

Department of Primary Education, School of Education, University of Ioannina, 451 10, Ioannina, Greece.

Objective: To inform the development of an AGREE II extension specifically tailored for surgical guidelines. AGREE II was designed to inform the development, reporting, and appraisal of clinical practice guidelines. Previous research has suggested substantial room for improvement of the quality of surgical guidelines.

Methods: A previously published search in MEDLINE for clinical practice guidelines published by surgical scientific organizations with an international scope between 2008 and 2017, resulted in a total of 67 guidelines. The quality of these guidelines was assessed using AGREE II. We performed a series of statistical analyses (reliability, correlation and Factor Analysis, Item Response Theory) with the objective to calibrate AGREE II for use specifically in surgical guidelines.

Results: Reliability/correlation/factor analysis and Item Response Theory produced similar results and suggested that a structure of 5 domains, instead of 6 domains of the original instrument, might be more appropriate. Furthermore, exclusion and re-arrangement of items to other domains was found to increase the reliability of AGREE II when applied in surgical guidelines.

Conclusions: The findings of this study suggest that statistical calibration of AGREE II might improve the development, reporting, and appraisal of surgical guidelines.
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http://dx.doi.org/10.1007/s00464-021-08604-wDOI Listing
August 2021

Advanced Modular Manikin and Surgical Team Experience During a Trauma Simulation: Results of a Single-Blinded Randomized Trial.

J Am Coll Surg 2021 08 27;233(2):249-260.e2. Epub 2021 May 27.

Division of Education, American College of Surgeons, Chicago, IL.

Background: Our aim was assess whether an integrated Advanced Modular Manikin (AMM) provides improved participant experience compared with use of peripheral simulators alone during a standardized trauma team scenario. Simulation-based team training has been shown to improve team performance. To address limitations of existing manikin simulators, the AMM platform was created that enables interconnectedness, interoperability, and integration of multiple simulators ("peripherals") into an adaptable, comprehensive training system.

Methods: A randomized single-blinded, crossover study with 2 conditions was used to assess learner experience differences when using the integrated AMM platform vs peripheral simulators. First responders, anesthesiologists, and surgeons rated their experience and workload with the conditions in a 3-scene standardized trauma scenario. Participant ratings were compared and focus groups conducted to obtain insight into participant experience.

Results: Fourteen teams (n = 42) participated. Team experience ratings were higher for the integrated AMM condition compared with peripherals (Cohen's d = .25, p = 0.016). Participant experience varied by background with surgeons and first responders rating their experience significantly higher compared with anesthesiologists (p < 0.001). Higher workload ratings were observed with the integrated AMM condition (Cohen's d = .35, p = 0.014) driven primarily by anesthesiologist ratings. Focus groups revealed that participants preferred the integrated AMM condition based on its increased realism, physiologic responsiveness, and feedback provided on their interventions.

Conclusions: This first comprehensive evaluation suggests that integration with the AMM platform provides benefits over individual peripheral simulators and has the potential to expand simulation-based learning opportunities and enhance learner experience, especially for surgeons.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.04.029DOI Listing
August 2021

Chylous ascites in the setting of internal hernia: a reassuring sign.

Surg Endosc 2021 May 14. Epub 2021 May 14.

Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA.

Background: Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients.

Methods: Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared.

Results: Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001).

Conclusions: Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.
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http://dx.doi.org/10.1007/s00464-021-08545-4DOI Listing
May 2021

Continuous, integrated sensors for predicting fatigue during non-repetitive work: demonstration of technique in the operating room.

Ergonomics 2021 Sep 11;64(9):1160-1173. Epub 2021 May 11.

School of Industrial Engineering, Purdue University, West Lafayette, IN, USA.

Surface electromyography (sEMG) can monitor muscle activity and potentially predict fatigue in the workplace. However, objectively measuring fatigue is challenging in complex work with unpredictable work cycles where sEMG may be influenced by the dynamically changing posture demands. This study proposes a multi-modal approach integrating sEMG with motion sensors and demonstrates the approach in the live surgical work environment. Seventy-two exposures from twelve participants were collected, including self-reported musculoskeletal discomfort, sEMG, and postures. Posture sensors were used to identify time windows where the surgeon was static and in non-demanding positions, and mean power frequencies (MPF) were then calculated during those time windows. In 57 out of 72 exposures (80%), participants experienced an increase in musculoskeletal discomfort. Integrated (multi-modality) measurements showed better performance than single-modality (sEMG) measurements in detecting decreases in MPF, a predictor of fatigue. Based on self-reported musculoskeletal discomfort, sensor-based thresholds for identifying fatigue are proposed for the trapezius and deltoid muscle groups. Work-related fatigue is one of the intermediate risk factors to musculoskeletal disorders. This article presents an objective integrated approach to identify musculoskeletal fatigue using wearable sensors. The presented approach could be implemented by ergonomists to identify musculoskeletal fatigue more accurately and in a variety of workplaces. sEMG: surface electromyography; IMU: inertia measurement unit; MPF: mean power frequency; ACGIH: American Conference of Governmental Industrial Hygienists; SAGES: Society of American Gastrointestinal and Endoscopic Surgeons; LD: left deltoid; LT: left trapezius; RD: right deltoid; RT: right trapezius.
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http://dx.doi.org/10.1080/00140139.2021.1909753DOI Listing
September 2021

A Competency-Based Laparoscopic Cholecystectomy Curriculum Significantly Improves General Surgery Residents' Operative Performance and Decreases Skill Variability: Cohort Study.

Ann Surg 2021 Mar 3. Epub 2021 Mar 3.

Indiana University School of Medicine, Department of Surgery, Indianapolis, IN.

Objective: To demonstrate the feasibility of implementing a competency-based education (CBE) curriculum within a general surgery residency program and to evaluate its effectiveness in improving resident skill.

Summary Background Data: Operative skill variability affects residents and practicing surgeons and directly impacts patient outcomes. CBE can decrease this variability by ensuring uniform skill acquisition. We implemented a CBE laparoscopic cholecystectomy (LC) curriculum to improve resident performance and decrease skill variability.

Methods: PGY-2 residents completed the curriculum during monthly rotations starting in July 2017. Once simulator proficiency was reached, residents performed elective LCs with a select group of faculty at three hospitals. Performance at curriculum completion was assessed using LC simulation metrics and intraoperative OPRS scores and compared to both baseline and historical controls, comprised of rising PGY-3 s, using a two-sample Wilcoxon rank-sum test. PGY-2 group's performance variability was compared with PGY-3 s using Levene's Robust Test of Equality of Variances; p < 0.05 was considered significant.

Results: 21 residents each performed 17.52 ± 4.15 consecutive LCs during the monthly rotation. Resident simulated and operative performance increased significantly with dedicated training and reached that of more experienced rising PGY-3 s (n = 7) but with significantly decreased variability in performance (p = 0.04).

Conclusions: Completion of a CBE rotation led to significant improvements in PGY-2 residents' LC performance that reached that of PGY-3 s and decreased performance variability. These results support wider implementation of CBE in resident training.
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http://dx.doi.org/10.1097/SLA.0000000000004853DOI Listing
March 2021

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines development: standard operating procedure.

Surg Endosc 2021 06 19;35(6):2417-2427. Epub 2021 Apr 19.

Department of Surgery, Stony Brook University, Stony Brook, USA.

Introduction: The mission of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is to innovate, educate, and collaborate to improve patient care. A critical element in meeting this mission is the publishing of trustworthy and current guidelines for the practicing surgeon.

Methods: In this manuscript, we outline the steps of developing high quality practice guidelines using a completely volunteer-based professional organization.

Results: SAGES has developed a standardized approach to train volunteer surgeons and trainees alike to develop clinically pertinent guidelines in a timely manner, without sacrificing quality.

Conclusions: This methodology can be used more widely by volunteer organizations to efficiently develop effective tools for practicing physicians.
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http://dx.doi.org/10.1007/s00464-021-08469-zDOI Listing
June 2021

Stress and resident interdisciplinary team performance: Results of a pilot trauma simulation program.

Surgery 2021 Oct 16;170(4):1074-1079. Epub 2021 Apr 16.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.

Background: Excessive stress negatively impacts surgical residents' technical performance. The effect of stress on trainee nontechnical skills, however, is less well studied. Given that nontechnical skills are known to impact clinical performance, the purpose of this study was to assess the relationship between residents' perceived stress and nontechnical skills during multidisciplinary trauma simulations.

Methods: First-year surgery and emergency medicine residents voluntarily participated in this study. Residents participated in 3 trauma simulations across 2 training sessions in randomly assigned teams. Each team's nontechnical skills were evaluated by faculty using the Trauma Nontechnical Skills scale. The Trauma Nontechnical Skills scale consists of 5 items: leadership, cooperation, communication, assessment, and situation awareness/coping with stress. After each scenario, residents completed the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index to detail their perceived stress and workload during scenarios. Linear regressions were run to assess relationships between stress, workload, and nontechnical skills.

Results: Twenty-five residents participated in the first simulation day, and 24 residents participated in the second simulation day. Results from regressions revealed that heightened stress and workload predicted significantly lower nontechnical skills performance during trauma scenarios. In regard to specific aspects of nontechnical skills, residents' heightened stress and workload predicted statistically significant lower situation awareness and decision-making during trauma scenarios.

Conclusion: Residents' perceived stress and workload significantly impaired their nontechnical skills during trauma simulations. This finding highlights the need to offer stress management and performance-optimizing mental skills training to trainees to lower their stress and optimize nontechnical skills performance during challenging situations.
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http://dx.doi.org/10.1016/j.surg.2021.03.010DOI Listing
October 2021

Multidisciplinary simulation-based trauma team training with an emphasis on crisis resource management improves residents' non-technical skills.

Surgery 2021 Oct 13;170(4):1083-1086. Epub 2021 Apr 13.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address:

Background: Non-technical skills impact trauma resuscitation time. Crisis resource management teaches non-technical skills required for effective teamwork in a crisis. We developed a simulation-based multidisciplinary trauma team training, with an emphasis on crisis resource management and a goal of improving residents' non-technical skills.

Methods: Twenty-five post-graduate year-1 general surgery and emergency medicine residents were divided into multidisciplinary teams with embedded nurse participants. Teams underwent 3 trauma resuscitation scenarios followed by a crisis resource management debrief. Additionally, a Just-In-Time crisis resource management didactic was delivered before 1 scenario. Teams' non-technical skills in each scenario were assessed by expert raters using non-technical skills scale for trauma and scenario scores before and after the Just-In-Time didactic were compared. Multiple linear-regression calculating the impact of clinical scenario, case order, and timing relative to the Just-In-Time didactic on a teams' non-technical skills scale for trauma score was performed.

Results: Seventy-four team T-NOTECHS ratings were completed. T-NOTECHS total score was significantly higher on the third training case regardless of clinical scenario or timing relative to the Just-In-Time didactic (pre = 15.58 vs post = 18.11, P = .117). Teams scored an average of 15.44 on the first scenario of the day, 16.63 on the second, and 19.04 on the last (P < .001).

Conclusion: Crisis resource management-focused multidisciplinary team training significantly improves residents' non-technical skills in the simulated environment. Case repetition followed by crisis resource management focused debriefings outweighed the effect of a single Just-In-Time crisis resource management didactic.
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http://dx.doi.org/10.1016/j.surg.2021.03.015DOI Listing
October 2021

Mastering Stress: Mental Skills and Emotional Regulation for Surgical Performance and Life.

J Surg Res 2021 07 5;263:A1-A12. Epub 2021 Mar 5.

Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

Mental skills and emotional regulation training are gaining acceptance in surgical education as vital elements of surgeon development. These skills can effectively enhance technical skill development, improve well-being, and promote career longevity. There is evidence emerging in the surgical education literature to support the incorporation of mental skills and emotional regulation training curricula in residency training. In this study, we present the existing evidence supporting the use of this training with high performers to reduce stress and optimize well-being and performance. We also consider the recent research emerging in surgical education that offers validity evidence for use of mental skills training with surgeons. Finally, we provide a framework to guide the incorporation of these skills throughout the career of a surgeon and suggest methods to promote the development of mental skills training efforts nationally.
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http://dx.doi.org/10.1016/j.jss.2021.01.009DOI Listing
July 2021

Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis.

Surg Endosc 2021 05 2;35(5):1949-1962. Epub 2021 Mar 2.

Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA.

Background: Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia.

Methods: We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively.

Results: From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events.

Conclusions: POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.
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http://dx.doi.org/10.1007/s00464-021-08353-wDOI Listing
May 2021

Surgical treatment of GERD: systematic review and meta-analysis.

Surg Endosc 2021 Aug 2;35(8):4095-4123. Epub 2021 Mar 2.

Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.

Background: Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

Methods: PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

Results: From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

Conclusions: The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08358-5DOI Listing
August 2021

Factors associated with weight regain post-bariatric surgery: a systematic review.

Surg Endosc 2021 Aug 1;35(8):4069-4084. Epub 2021 Mar 1.

Department of Surgery, Section of Bariatric and Minimally Invasive Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 130, Indianapolis, IN, 46202, USA.

Introduction: To systematically review the literature to assess the incidence and risk factors of weight regain (WR) after bariatric surgery. Bariatric surgery is the most effective intervention for sustained weight loss of morbidly obese patients, but WR remains a concern.

Materials And Methods: A PRISMA compliant systematic literature review was performed using the PubMed database, Embase and the Cochrane Library in July of 2019. Studies that reported ≥ 10% WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were included. The Newcastle-Ottawa scale (NOS) was used for assessing study quality.

Results: Out of 2915 retrieved abstracts, 272 full papers were reviewed, and 32 studies included (25 of high and 7 of fair quality) reporting weight outcomes on 7391 RYGB and 5872 SG patients. 17.6% (95% CI 16.9-18.3) had a WR ≥ 10%. Risk factors related with WR fell into 5 categories, namely anatomical, genetic, dietary, psychiatric, and temporal. Specifically, gastrojejunal stoma diameter, gastric volume following sleeve, anxiety, time after surgery, sweet consumption, emotional eating, portion size, food urges, binge eating, loss of control/disinhibition when eating, and genetics have been positively associated with WR while postprandial GLP-1, eagerness to change physical activity habits, self-esteem, social support, fruit and zinc consumption, HDL, quality of life have been negatively associated.

Conclusion: At least 1 in 6 patients after bariatric surgery had ≥ 10% WR. This review identified several factors related to WR that can be used to counsel patients preoperatively and direct postoperative strategies that minimize WR risk.
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http://dx.doi.org/10.1007/s00464-021-08329-wDOI Listing
August 2021

Characterizing robotic surgical expertise: An exploratory study of neural activation during mental imagery of robotic suturing.

Am J Surg 2021 Feb 9. Epub 2021 Feb 9.

Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 111, Indianapolis, IN, 46202, USA. Electronic address:

Background: Mental imagery (MI) aids skill acquisition, however, it is unclear to what extend MI is used by experienced surgeons. The purpose of this study was to assess differences in MI of participants with varying surgical expertise in robotic surgery.

Methods: Students, residents, and surgeons completed the Mental Imagery Questionnaire to assess MI for robotic suturing. Participants then completed robotic simulator tasks, and imagined performing robotic suturing while being assessed with electroencephalogram (EEG).

Results: Attending surgeons reported higher MI for robotic suturing, and EEG revealed higher neural activation during imagery of robotic suturing than other groups.

Conclusions: Experienced surgeons displayed higher MI ability for robotic suturing, and displayed higher cortical activity in the frontal and parietal areas of the brain, which is associated with more advanced motor imagery. MI appears to be a component of robotic surgery expertise.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.002DOI Listing
February 2021

SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia.

Surg Endosc 2021 05 9;35(5):1931-1948. Epub 2021 Feb 9.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia.

Results: The panel agreed on 4 recommendations for adults and children with achalasia.

Conclusions: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.
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http://dx.doi.org/10.1007/s00464-020-08282-0DOI Listing
May 2021

Surgeon stress negatively affects their non-technical skills in the operating room.

Am J Surg 2021 Jan 30. Epub 2021 Jan 30.

Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 111, Indianapolis, IN, 46202, USA. Electronic address:

Background: Poor surgeons' non-technical skills (NTS) and excessive stress and workload are known contributors to surgical errors. Our aim was to examine the relationship between surgeons' stress and workload, and their observed NTS intraoperatively.

Methods: Surgeon's NTS were rated in the operating room (OR) by trained observers. Surgeon stress, workload, familiarity with the OR team, prior experience, and case difficulty were captured. Relationships between variables were assessed.

Results: Fifteen surgeons participated in our study. Agreement among raters was high for NTS observations (ICC range = 0.56-0.96). Stress was negatively correlated with situation awareness, and workload was negatively correlated with decision making. Less familiarity among the team was correlated with higher stress.

Conclusions: Surgeons' stress and workload negatively affected their NTS in the OR. Further, unfamiliarity with the surgical team contributed to surgeon's stress. Methods to reduce surgeons' stress and workload such as mental skills training should be considered.
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http://dx.doi.org/10.1016/j.amjsurg.2021.01.035DOI Listing
January 2021

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

J Gastrointest Surg 2021 Feb 2. Epub 2021 Feb 2.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

Methods: A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

Results: The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

Conclusion: One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.
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http://dx.doi.org/10.1007/s11605-021-04930-5DOI Listing
February 2021

SAGES guidelines: an appraisal of their quality and value by SAGES members.

Surg Endosc 2021 04 2;35(4):1493-1499. Epub 2021 Feb 2.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee develops evidence-based guidelines for practicing surgeons using standard methodology. Our objective was to survey the SAGES membership regarding guidelines' quality, use, and value and identify topics of interest for new guideline development.

Methods: An anonymous online survey was emailed in October 2019 to SAGES members. Respondents were asked 18 questions on their use and evaluation of SAGES guidelines and SAGES reviews and to provide suggestions for new guideline topics and areas of improvement. The survey was open for 6 weeks with a 3-week reminder.

Results: Of 548 responders, most were minimally invasive (41%) or general surgeons (33%). There was an even distribution between academic (46%) and non-academic practice (24% private practice, 23% hospital employed). Most used SAGES guidelines frequently (22%) or occasionally (68%) and found them to be of value (83%), above average quality (86%), and easy to use (74%). While most stated it was important (35%) or very important (58%) that SAGES continues to follow "rigorous guidelines development processes," common suggestions were for more timely updates and improved web access. Of 442 overlapping topic suggestions, 60% fell into overarching categories of hernia, bariatric, robotic, HPB, and colorectal surgery.

Conclusions: The SAGES guidelines are used frequently and valued by its users for their quality and content. Topics proposed by SAGES members and valuable insight from this survey can guide creation of new guidelines and refinement of established guidelines and processes.
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http://dx.doi.org/10.1007/s00464-021-08323-2DOI Listing
April 2021

How are bariatric patients coping during the coronavirus disease 2019 (COVID-19) pandemic? Analysis of factors known to cause weight regain among postoperative bariatric patients.

Surg Obes Relat Dis 2021 04 28;17(4):756-764. Epub 2020 Nov 28.

Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery, Indiana University Health North Hospital, Indianapolis, Indiana. Electronic address:

Background: The global coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc on society. Bariatric patients are more prone to severe infection due to their high body mass index (BMI) and are more vulnerable to the effects of isolation, such as depression or disruption of their health habits.

Objectives: To quantify the impact of self-quarantine on bariatric patients and self-quarantine's relationship with weight gain.

Setting: Academic hospital, United States.

Methods: A 30-item survey examining several known contributors to weight regain was distributed among the postoperative bariatric patients of our clinic. Changes in eating habits, exercise, depression, social support, loneliness, and anxiety were studied, among others.

Results: A total of 208 patients completed the survey (29.3% response rate). A large percentage of patients reported increases in their depression (44.2%), loneliness (36.2%), nervousness (54.7%), snacking (62.6%), loss of control when eating (48.2%), and binge eating (19.5%) and decreases in their social support (23.2%), healthy food eating (45.5%), and activity (55.2%). Difficulty in accessing vitamins was reported by 13%. Patients more than 18 months out of surgery regained more than 2 kg during an average of 47 days. Risk factors for weight regain were found to be loss of control when eating, increases in snacking and binge eating, reduced consumption of healthy food, and reduced physical activity.

Conclusion: Bariatric patients are negatively affected by the COVID-19 pandemic and subsequent social isolation on many levels. This patient population is vulnerable to crisis situations; thus, additional intervention is needed to address behaviors that lead to weight regain.
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http://dx.doi.org/10.1016/j.soard.2020.11.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699156PMC
April 2021

Disparate opinions on the value of Vice Chairs of education in Departments of Surgery: A national survey of Department Chairs and other surgical education stakeholders.

Am J Surg 2021 02 30;221(2):381-387. Epub 2020 Nov 30.

University of Utah, Department of Surger, Division of Vascular Surgery, USA. Electronic address:

Background: The position of Vice Chair of Education (VCE) is increasingly common in Surgery Departments. The role remains ill-defined. The purpose of this study was to explore perceptions of Department Chairs (DCs) and Other Education Stakeholders (OESs) regarding the VCE role.

Methods: DCs and OESs at institutions with a VCE were surveyed. Descriptive statistics and cross-tabulations were calculated (SAS V9.4).

Results: The overall response rate was 25% (166/666). There were significant differences in whether DCs and OESs agree that the VCE supports others in fulfilling educational roles (95.2% vs 49.5%, p = 0.0002), is critical in achieving education missions (90.5% vs 56.6%, p = 0.0032), enhances the quality of education (95.3% vs 65.7%, p = 0.0174), and is important to education teams (95.0% vs 68.7%, p = 0.0464).

Conclusions: DCs value the VCE role more so than OESs, whom VCEs support. In order for VCEs to be effective educational leaders in Departments of Surgery, the needs of key stakeholders deserve further clarification.
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http://dx.doi.org/10.1016/j.amjsurg.2020.11.036DOI Listing
February 2021

Response to: "Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial": Not only surgeon's manual skills..."

Ann Surg 2020 Dec 3. Epub 2020 Dec 3.

Department of Surgery, University of Washington Medical Center, Seattle, WA Department of Surgery, Indiana University School of Medicine, Indianapolis, IN Department of Ob/Gyn, Drexel University College of Medicine, Institute of Surgical Excellence, Philadelphia, PA Florida Hospital Nicholson Center, University of Central Florida College of Medicine, Celebration, FL Department of Surgery, Indiana University School of Medicine, Indianapolis, IN Department of Surgery, St. Mary's Hospital, Imperial College, London, United Kingdom EndoCAS Simulation Center, University of Pisa, Pisa, Italy Andersen Simulation Center, Madigan Army Medical Center, Tacoma, WA Center for Education, Simulation and Innovation, Hartford Hospital, Hartford, CT Penn Medicine Clinical Simulation Center, Philadelphia, PA Department of Colon and Rectal Surgery, Lahey Health and Medical Center, Burlington, MA National and Kapodistrian University of Athens, Athens, Greece Houston Methodist Hospital, Methodist Institute for Technology, Innovation, and Education, Houston, TX USF Health Center for Advanced Medical Learning and Simulation, Tampa, FL Lehigh Valley Health Network, Allentown PA Department of Surgery, Surgical Education and Activities Lab, Duke University Medical Center, Durham, NC Department of Surgery, St. Mary's Hospital, Imperial College, London, United Kingdom Director of Technology Enhanced Learning, ASSERT Centre, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1097/SLA.0000000000004658DOI Listing
December 2020

An analysis of the ergonomic risk of surgical trainees and experienced surgeons during laparoscopic procedures.

Surgery 2021 03 25;169(3):496-501. Epub 2020 Nov 25.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address:

Background: Work-related musculoskeletal injuries have been increasingly recognized to affect surgeons. It is unknown whether such injuries also affect surgical trainees. The purpose of this study was to assess the ergonomic risk of surgical trainees as compared with that of experienced surgeons.

Methods: Ergonomic data were recorded from 9 surgeons and 11 trainees. Biomechanical loads during surgery were assessed using motion tracking sensors and electromyography sensors. Demanding and static positions of the trunk, neck, right/left shoulder, as well as activity from the deltoid and trapezius muscles bilaterally were recorded. In addition, participants reported their perceived discomfort on validated questionnaires.

Results: A total of 87 laparoscopic general surgery cases (48 attendings and 39 trainees) were observed. Both trainees and attendings spent a similarly high percentage of each case in static (>60%) and demanding positions (>5%). Even though residents reported overall more discomfort, all participants shared similar ergonomic risk with the exception of trainees' trunk being more static (odds ratio: -11.42, P = .006).

Conclusion: Surgeons are prone to ergonomic risk. Trainees are exposed to similar postural ergonomic risk as surgeons but report more discomfort and, given that musculoskeletal injuries are cumulative over time, the focus should be on interventions to reduce ergonomic risk in the operating room.
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http://dx.doi.org/10.1016/j.surg.2020.10.027DOI Listing
March 2021

What are the Top Research Priorities in Surgical Simulation and How Can They Be Best Addressed? Results from a Multidisciplinary Consensus Conference.

Ann Surg 2020 Nov 23. Epub 2020 Nov 23.

Division of Education, American College of Surgeons, Chicago, IL.

Objectives: To define the top priorities in simulation-based surgical education where additional research would have the highest potential to advance the field and develop proposals that would address the identified research priorities.

Summary And Background Data: Simulation has become integral part of surgical training but there are a number of outstanding questions that have slowed advances in this field.

Methods: The Delphi methodology was used to define the top priorities in simulation-based surgical education. A research summit was held with multiple stakeholders under the auspices of the American College of Surgeons Division of Education to develop proposals to address these priorities.

Results: Consensus was achieved after the first round of voting on the following three most important topics: 1) impact of simulation training on patient safety and outcomes, 2) the value proposition of simulation, and 3) the use of simulation for physician certification and credentialing. Knowledge gaps, challenges and opportunities, and research questions to address these topics were defined by summit participants.

Conclusions: The top 3 priorities in surgical simulation research were defined and project outlines were developed for impactful projects on these topics. Successful completion of such projects is expected to advance the field of simulation-based surgical education.
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http://dx.doi.org/10.1097/SLA.0000000000004651DOI Listing
November 2020

Expert Consensus Recommendations for Robotic Surgery Credentialing.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Institute for Surgical Excellence. Washington, DC.

Objective: To define criteria for robotic credentialing using expert consensus.

Background: A recent review of institutional robotic credentialing policies identified significant variability and determined current policies are largely inadequate to ensure surgeon proficiency and may threaten patient safety.

Methods: 28 national robotic surgery experts were invited to participate in a consensus conference. After review of available institutional policies and discussion, the group developed a 91 proposed criteria. Using a modified Delphi process the experts were asked to indicate their agreement with the proposed criteria in three electronic survey rounds after the conference. Criteria that achieved 80% or more in agreement (consensus) in all rounds were included in the final list.

Results: All experts agreed that there is a need for standardized robotic surgery credentialing criteria across institutions that promote surgeon proficiency. 49 items reached consensus in the first round, 19 in the second, and 8 in the third for a total of 76 final items. Experts agreed that privileges should be granted based on video review of surgical performance and attainment of clearly defined objective proficiency benchmarks. Parameters for ongoing outcome monitoring were determined and recommendations for technical skills training, proctoring, and performance assessment were defined.

Conclusions: Using a systematic approach, detailed credentialing criteria for robotic surgery were defined. Implementation of these criteria uniformly across institutions will promote proficiency of robotic surgeons and has the potential to positively impact patient outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000004531DOI Listing
November 2020

Association of Medical Students' Stress and Coping Skills With Simulation Performance.

Simul Healthc 2021 Oct;16(5):327-333

From the Department of Surgery (N.E.A., M.A.R., J.M.H., K.J.S.-M., D.S.), Indiana University School of Medicine; and Simulation Center at Fairbanks Hall (R.S.), Indiana University Health, Indianapolis, IN.

Introduction: Medical students are vulnerable to experience stress, as they are routinely confronted with stressors. Acute stress can reduce students' performance on examinations, and chronic stress can contribute to cognitive disorders. Conversely, stress coping skills can reduce trainees' anxiety. Thus, stress coping skills may help students manage stress effectively and better maintain clinical performance. The goal of this study was to assess the relationship between medical students' stress, workload, stress coping skills, performance-enhancing mental skills, and clinical performance during a simulated clinical scenario.

Methods: During their surgery clerkship rotation, third-year medical students participated in a simulated scenario designed to assess their ability to care for an acutely ill surgical patient. Participants' physiological stress was assessed using heart rate (HR) monitors during the simulation, their perceived stress using the State-Trait Anxiety Inventory, and workload using the NASA-Task Load Index immediately after. Clinical performance was assessed using a global rating scale. Stress coping skills were also assessed. The relationship between performance, stress level, workload, and coping skills was examined.

Results: Forty-one third-year medical students voluntarily participated in the study. Participants' clinical performance was negatively correlated with perceived stress and workload during the scenario (P < 0.05). A stepwise linear regression model revealed that higher HR was the main predictor of poorer clinical performance (P < 0.05).

Conclusions: In this study, medical students' HR was associated with poorer performance during a simulated clinical scenario. Adaptive stress coping skills may allow medical students to manage stressful situations and better maintain performance.
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http://dx.doi.org/10.1097/SIH.0000000000000511DOI Listing
October 2021
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