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1.  The feasibility of performing a randomised controlled trial for femoroacetabular impingement surgery 
Bone & Joint Research  2013;2(2):33-40.
Objectives
The number of surgical procedures performed each year to treat femoroacetabular impingement (FAI) continues to rise. Although there is evidence that surgery can improve symptoms in the short-term, there is no evidence that it slows the development of osteoarthritis (OA). We performed a feasibility study to determine whether patient and surgeon opinion was permissive for a Randomised Controlled Trial (RCT) comparing operative with non-operative treatment for FAI.
Methods
Surgeon opinion was obtained using validated questionnaires at a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely performed FAI surgery) and patient opinion was obtained from clinical patients with a new diagnosis of FAI (n = 31).
Results
Clinical equipoise was demonstrated when surgeons were given clinical scenarios and asked whether they would manage a patient operatively or non-operatively. A total of 23 surgeons (77%) who routinely perform FAI surgery were willing to recruit patients into a RCT, and 28 patients (90%) were willing to participate. 75% of responding surgeons believed it was appropriate to randomise patients to non-operative treatment for ≥ 12 months. Conversely, only eight patients (26%) felt this was acceptable, although 29 (94%) were willing to continue non-operative treatment for six months. More patients were concerned about their risk of developing OA than their current symptoms, although most patients felt that the two were of equal importance.
Conclusions
We conclude that a RCT comparing operative and non-operative management of FAI is feasible and should be considered a research priority. An important finding for orthopaedic surgical trials is that patients without life-threatening pathology appear willing to trial a treatment for six months without improvement in their symptoms.
doi:10.1302/2046-3758.22.2000137
PMCID: PMC3626218  PMID: 23610700
Femoroacetabular impingement; Randomised controlled trial; Hip; Feasibility; Equipoise; Trial design
2.  Cataract surgery under topical anesthesia using 2% lignocaine jelly and intracameral lignocaine: Is manual small incision cataract surgery comparable to clear corneal phacoemulsification? 
Indian Journal of Ophthalmology  2010;58(6):537-540.
A prospective comparative study was undertaken to compare the patients’ pain experience, surgical outcome and surgeon’s experience in phacoemulsification and manual small incision cataract surgery (MSICS) under topical anesthesia supplemented with intracameral lignocaine (TASIL). In Group 1 (n=88) phacoemulsification was done and in Group 2 (n=92) MSICS was done. Pain scores were marked by the patients on a Visual analog scale (VAS) after the surgery. The surgical experience was noted on a questionnaire by the operating surgeon. Descriptive analysis and one-tailed Mann-Whitney test were used to draw results. The average VAS score in Group 1 was 0.65 (SD 1.31) and in Group 2 it was 0.90 (SD 1.22). This difference in the average was not statistically significant with P=0.09. The study demonstrates that MSICS and phacoemulsification both can be done safely under TASIL with acceptable patient comfort, and the pain experienced by the patients during the procedures is comparable.
doi:10.4103/0301-4738.71713
PMCID: PMC2993990  PMID: 20952844
Manual small incision cataract surgery; phacoemulsification; topical anesthesia; Visual analog scale; pain evaluation; gender; cataract. intracameral lignocaine
3.  Emergent management of postpartum hemorrhage for the general and acute care surgeon 
Background
Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.
Methods
The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion.
Results
A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm.
Conclusion
The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.
doi:10.1186/1749-7922-4-43
PMCID: PMC2788527  PMID: 19939251
4.  SURGEONS EXPECT PATIENTS TO BUY-IN TO POSTOPERATIVE LIFE SUPPORT PREOPERATIVELY: RESULTS OF A NATIONAL SURVEY 
Critical care medicine  2013;41(1):1-8.
Objective
Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high risk operations.
Design
Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with a) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and b) declining to operate on such patients.
Setting and subjects
US-mail based survey of 2100 cardiothoracic, vascular and neurosurgeons.
Interventions
None.
Measurements and Main Results
The adjusted response rate was 56%. Nearly two-thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life supporting therapy were more than twofold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 as compared to those who felt it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3-3.2).
Conclusions
Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.
doi:10.1097/CCM.0b013e31826a4650
PMCID: PMC3624612  PMID: 23222269
ethics; decision making; patient autonomy; informed consent; surgical outcomes
5.  A survey of the current practice of the informed consent process in general surgery in the Netherlands 
Background
A properly conducted surgical informed consent process (SIC) allows patients to authorize an invasive procedure with full comprehension of relevant information including involved risks. Current practice of SIC may differ from the ideal situation. The aim of this study is to evaluate whether SIC practiced by Dutch general surgeons and residents is adequate with involvement of all required elements.
Methods
All members of the Dutch Society of Surgery received an online multiple choice questionnaire evaluating various aspects of SIC.
Results
A total of 453 questionnaires obtained from surgeons and residents representing >95% of all Dutch hospitals were eligible for analysis (response rate 30%). Knowledge on SIC was limited as only 55% was familiar with all three basic elements (‘assessment of preconditions’, ‘provision of information’ and ‘stage of consent’). Residents performance was inferior compared to surgeons regarding most aspects of daily practice of SIC. One in 6 surgeons (17%) had faced a SIC-related complaint in the previous five years possibly illustrating suboptimal SIC implementation in daily surgical practice.
Conclusions
The quality of the current SIC process is far from optimal in the Netherlands. Surgical residents require training aimed at improving awareness and skills. The SIC process is ideally supported using modern tools including web-based interactive programs. Improvement of the SIC process may enhance patient satisfaction and may possibly reduce the number of complaints.
doi:10.1186/1754-9493-7-4
PMCID: PMC3804026  PMID: 23336609
Informed consent; Surgery; Patient education; Questionnaire; Interactive tools; Training
6.  Surgeons’ opinions and practice of informed consent in Nigeria 
Journal of Medical Ethics  2010;36(12):741-745.
Background
Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed.
Methods
A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires.
Results
There were 102 respondents, 85.3% of whom were men and 58.8% were aged 31–40 years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons (70.6%), informing patients about benefits, risks and alternatives (64.7%) and hospital policy (50.0%) as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients.
Conclusion
Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon–patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement.
doi:10.1136/jme.2010.037440
PMCID: PMC3332031  PMID: 20940174
7.  Discrepant perceptions of communication, teamwork and situation awareness among surgical team members 
Objective
To assess surgical team members’ differences in perception of non-technical skills.
Design
Questionnaire design.
Setting
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Participants
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
Methods
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Results
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
Conclusions
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
doi:10.1093/intqhc/mzq079
PMCID: PMC3055275  PMID: 21242160
patient safety; quality of care; teamwork; communication; surgery
8.  The value of “another” opinion for spinal surgery: A prospective 14-month study of one surgeon's experience 
Surgical Neurology International  2012;3(Suppl 5):S350-S354.
Background:
Neck or back problems are experienced at some time by many Americans and many patients receive recommendations for spinal surgery. Patients naturally seek another opinion to confirm the need for surgery, or for the particular procedure recommended.
Methods:
Over approximately a 14-month period, the author prospectively collected data regarding 240 consecutive patients seeking a surgical opinion regarding a spine problem. Imaging studies were reviewed and patients were asked to comment on the consultation experience.
Results:
Of the 240 patients, 155 (65%) came for a second, third, or fourth surgical opinion following an earlier opinion from a surgeon who recommended an operation. Of these patients, the author recommended no surgery for 69 (44.5%) patients. The remaining 85 (35%) were referred by primary care doctors or neurologists for initial surgical (first) opinions because of magnetic resonance imaging (MRI) or computed tomography (CT) reports indicating the presence of surgical lesions. The author recommended no surgery for 37 (43%) of these 85 patients.
Conclusions:
Patients request and deserve the attention of a physician who will listen to their history and perform a careful neurological examination. The results of the neurological examination and the imaging studies must then be carefully integrated and correlated with the patient's complaints. The results should be explained to the patient so that he or she will understand the surgical or non surgical nature of his or her problem.
doi:10.4103/2152-7806.103867
PMCID: PMC3520076  PMID: 23248753
Imaging studies; not satisfied; spinal surgery; very helpful
9.  Why Are Spine Surgery Patients Lost to Follow-up? 
Global Spine Journal  2013;3(1):15-20.
Long-term outcome studies are frequently hindered by a decreasing frequency of patient follow-up with the treating surgeon over time. Whether this attrition represents a “loss of faith” in their index surgeon or the realities of a geographically mobile society has never been assessed in a population of patients undergoing spinal surgery. The purpose of this article is to determine the frequency with which patients who have undergone prior surgery and develop new problems attempt to follow-up with their index spine surgeon. The study design was a population survey. All patients seen at two university-based spine centers over a 3-month period were surveyed regarding prior spine surgery. The questionnaire asked details of the previous operation, whether the patient had sought follow-up with their index surgeon, why the patient did not continue treatment with that surgeon, and whether the patient was satisfied with their prior treatment. Sixty-nine patients completed the survey. Prior operations were lumbar (53 patients) and cervical (16). When asked the reason for not seeing their prior surgeon, 10 patients (15%) stated that they (the patient) had moved and 16 (23%) responded that their surgeon no longer practiced in the area. Thirteen (19%) were unhappy with their previous care, 22 (32%) were seeking a second opinion, and 7 (10%) were told they needed more complex surgery. Thirty-seven (54%) discussed their symptoms with their original surgeon before seeking another surgeon. Although 32 patients (46%) had not discussed their new complaints with their index surgeon, only 3 patients (4%) chose not to return to their prior surgeon despite having the opportunity to do so. Forty-nine patients (71%) were satisfied with their prior surgical care, and 42 patients (61%) would undergo the index operation again. Most of the patients seen at the authors' practices after undergoing prior spine surgery elsewhere failed to follow up with their prior spine surgeon for geographical reasons. It appears that the majority of patients who develop new spinal complaints will seek out their treating surgeon when possible. This suggests that patient attrition over long-term follow-up may reflect a geographically mobile population rather than patient dissatisfaction with prior treatment.
doi:10.1055/s-0033-1337120
PMCID: PMC3854586  PMID: 24436847
loss to follow-up; spine surgery; second opinion; revision spinal surgery; clinical studies
10.  The Case for Standardisation of the Management of Gallstones Spilled and not Retrieved at Laparoscopic Cholecystectomy 
INTRODUCTION
This observational study was carried out to establish how surgeons performing laparoscopic cholecystectomy currently deal with the issue of spilled gallstones.
MATERIALS AND METHODS
A questionnaire was circulated amongst laparoscopic surgeons attending the annual conference of the Association of Laparoscopic Surgery of Great Britain and Ireland in November 2006.
RESULTS
Eighty-two surgeons completed the questionnaire. Only half of surgeons inform patients when gallstones are spilled. Less than 30% of surgeons inform general practitioners (GPs) of this complication, when it occurs. Less than a quarter of surgeons include this information in the consent literature provided to patients.
CONCLUSIONS
We recommend that trusts review their policy towards spilled stones either by local audit or adopt the guidance given by the UK Healthcare Commission. While some surgeons feel informing patients and GPs may unnecessarily heighten anxiety from an uncommon complication, our review of the literature suggests this position is not tenable in the current medicolegal climate.
doi:10.1308/003588408X285883
PMCID: PMC2647193  PMID: 18492395
Laparoscopic cholecystectomy; Spilled gallstones
11.  Patient Safety in the Operating Room 
Seminars in Plastic Surgery  2006;20(4):214-218.
ABSTRACT
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during elective cosmetic surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementation of patient safety guidelines by the plastic surgeon is of increasing importance.
Key aspects of patient safety in the operating room include thoughtful patient positioning, ocular protection, proper handling of electrocautery, and airway management. If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain. In this article we discuss proper patient positioning with attention to protection against nerve palsy. Further, we discuss common patient positions on the operative table and highlight special concerns associated with each position. Other safety issues including prevention of ocular injury and proper management of electrocautery are discussed.
Responsibility of postoperative complications ultimately lies with the surgeon. Careful attention to patient safety guidelines is of paramount importance to surgeons, especially during elective cosmetic procedures. Attention to detail in patient positioning, eye protection, and bovie use can help avoid unnecessary perioperative complications and significantly improve the patient's cosmetic surgery experience.
doi:10.1055/s-2006-951578
PMCID: PMC2884786
Patient safety; operating room; patient positioning; ocular injury; electrosurgery; nerve injury
12.  Informed consent: a case for more education of the surgical team. 
A questionnaire was given to 37 members of staff of the Department of Surgery, Addenbrooke's Hospital, Cambridge, in order to determine whether their knowledge was adequate to give accurate information to patients regarding operations and thus to obtain properly informed consent for that operation. Each participant was asked to estimate the 24-h and 30-day mortality for five common elective operations. A wide range of answers was given for operations by all groups. Estimates of 24-h mortality after unilateral inguinal herniorrhaphy differed between staff grades by a factor of 3, but estimates of 24-h mortality after thyroidectomy differed by a factor of 100 between consultant surgeons and staff nurses. Our findings suggest that some members of the surgical team have insufficient knowledge about common operations to obtain properly informed consent from patients.
PMCID: PMC2497732  PMID: 8422148
13.  What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories 
Quality & safety in health care  2005;14(6):414-416.
Background: Surgical patients may be at risk for medication discrepancies that may lead to medication errors because both the anesthesiologist and the surgeon write separate preoperative medication histories.
Methods: A prospective observational study was conducted to examine the extent of medication and allergy discrepancies between surgical and anesthesia preoperative medication histories for patients admitted to two surgical intensive care units in an academic medical center.
Results: Of the 79 patient records reviewed, 58 (73%) contained at least one discrepancy, 23% had different allergy information, 56% had different preoperative medications, and 43% had different doses or dosing frequencies listed in the medication histories. Of the 988 allergies, medications, and doses or dosing frequencies documented in the two histories, 456 (46%) contained discrepancies. Of these discrepancies, 20 (5%) were due to different allergies, 293 (64%) to different medications, and 143 (31%) to different doses or dosing frequencies.
Conclusions: Discrepancies in preoperative medication histories between surgical and anesthesia records occur in most patients and further work is required to help improve agreement of patient medication histories between services.
doi:10.1136/qshc.2005.014738
PMCID: PMC1744102  PMID: 16326785
14.  The use of physical biomodelling in complex spinal surgery 
European Spine Journal  2007;16(9):1507-1518.
Prior studies have suggested that biomodels enhance patient education, preoperative planning and intra-operative stereotaxy; however, the usefulness of biomodels compared to regular imaging modalities such as X-ray, CT and MR has not been quantified. Our objective was to quantify the surgeon’s perceptions on the usefulness of biomodels compared to standard visualisation modalities for preoperative planning and intra-operative anatomical reference. Physical biomodels were manufactured for a series of 26 consecutive patients with complex spinal pathologies using a stereolithographic technique based on CT data. The biomodels were used preoperatively for surgical planning and customising implants, and intra-operatively for anatomical reference. Following surgery, a detailed biomodel utility survey was completed by the surgeons, and informal telephone interviews were conducted with patients. Using biomodels, 21 deformity and 5 tumour cases were performed. Surgeons stated that the anatomical details were better visible on the biomodel than on other imaging modalities in 65% of cases, and exclusively visible on the biomodel in 11% of cases. Preoperative use of the biomodel led to a different decision regarding the choice of osteosynthetic materials used in 52% of cases, and the implantation site of osteosynthetic material in 74% of cases. Surgeons reported that the use of biomodels reduced operating time by a mean of 8% in tumour patients and 22% in deformity procedures. This study supports biomodelling as a useful, and sometimes essential tool in the armamentarium of imaging techniques used for complex spinal surgery.
doi:10.1007/s00586-006-0289-3
PMCID: PMC2200746  PMID: 17846803
Biomodelling; Complex spinal surgery; Rapid prototyping; Stereolithography; Spinal deformity; Spine surgery planning
15.  Informed consent for innovative surgery: A survey of patients and surgeons 
Surgery  2012;153(4):473-480.
Background
Unlike new drugs and medical devices, most surgical procedures are developed outside clinical trials, without regulatory oversight. Surgical professional organizations have discussed how new procedures should be introduced into practice, without agreement on what topics informed consent discussions must include. To provide surgeons with more specific guidance, we wanted to determine what information patients and surgeons consider essential to disclose before an innovative surgical procedure.
Methods
85 attending surgeons and 383 adult postoperative patients completed surveys. Using a 6-point Likert scale, participants rated the importance of discussing 16 types of information preoperatively for 3 techniques (standard open, laparoscopic, robotic) offered for a hypothetical partial hepatectomy.
Results
Compared with surgeons, patients placed more importance on nearly all types of information, particularly volumes and outcomes. For all 3 techniques, around 80% of patients indicated that they could not decide on surgery without being told whether it would be the surgeon’s first time doing the procedure. When considering an innovative robotic surgery, a clear majority of both patients and surgeons agreed that it was essential to disclose the procedure’s novel nature, potentially unknown risks and benefits, and whether it would be the surgeon’s first time performing the procedure.
Conclusions
To promote informed decision making and autonomy among patients considering innovative surgery, surgeons should disclose the procedure’s novel nature, potentially unknown risks and benefits, and whether the surgeon would be performing the procedure for the first time. When accurate volumes and outcomes data are available, surgeons should also discuss these with patients.
doi:10.1016/j.surg.2012.08.068
PMCID: PMC3602241  PMID: 23218878
16.  Are recommended spine operations either unnecessary or too complex? Evidence from second opinions 
Surgical Neurology International  2013;4(Suppl 5):S353-S358.
Background:
In 2011, Epstein and Hood documented that 17.2% of 274 patients with cervical/lumbar complaints seen in first or second opinion over one year were told they needed “unnecessary” spine surgery (e.g., defined as for pain alone, without neurological deficits, or significant radiographic abnormalities). Subsequently, in 2012 Gamache found that 69 (44.5%) of the 155 second opinion patients seen over a 14-month period were told by outside spine surgeons that they needed surgery; the second opinion surgeon (Gamache) found those operations to be unnecessary. Increasingly, patients, spine surgeons, hospitals, and insurance carriers should not only be questioning whether spinal operations are “unnecessary”, but also whether they are “wrong” (e.g., overly extensive, anterior vs. posterior operations), or “right” (appropriate).
Methods:
Prospectively, 437 patients with cervical or lumbar complaints were seen in spinal consultation over a 20-month period. Of the 254 (58.1%) patients coming in for first opinions those with surgical vs. non-surgical lesions were identified. Of the 183 (41.9%) patients coming in for second opinions, who were previously told by outside surgeons that they needed spine operations, the second opinion surgeon documented the number of “unnecessary”, “wrong”, or “right” operations previously recommended.
Results:
Surgical pathology was identified in 138 (54.3%) patients presenting for first opinions. For patients seen in second opinion, 111 (60.7%) were told by outside surgeons that they required “unnecessary”, 61 (33.3%) the “wrong”, or 11 (6%) the “right” operations.
Conclusions:
Of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%), or the “right” (6%) operations.
doi:10.4103/2152-7806.120774
PMCID: PMC3841934  PMID: 24340231
First opinions; right; spine surgery; second opinions; unnecessary; wrong
17.  Patient satisfaction with perioperative care among patients having orthopedic surgery in a university hospital 
This survey aimed to validate the English version of the multidimensional Leiden Perioperative Patient Satisfaction questionnaire (LPPSq) and use it to assess patient satisfaction with perioperative care and the influence of type of anesthesia. One hundred patients having orthopedic surgery under regional and general anesthesia verbally consented to participate. Different aspects of satisfaction were assessed (eg, provision of information, and staff-patient relationship). The reliability estimate of the LPPSq (Cronbach’s-α) was good (0.94). Overall, patient satisfaction score was 86.7%, lowest was for information (80.8%) and highest for staff-patient relationships (90.3%). Patients were more satisfied with the provision of information regarding regional anesthesia.
PMCID: PMC3417948  PMID: 22915869
Leiden Perioperative Patient Satisfaction questionnaire; orthopedic; anesthesia; information
18.  Children's surgery: a national survey of consultant clinical practice 
BMJ Open  2012;2(5):e001639.
Objectives
To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK.
Design
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children.
Setting
The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals.
Participants
555 surgeons and 1561 anaesthetists completed the questionnaire.
Results
32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery.
Conclusions
There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.
doi:10.1136/bmjopen-2012-001639
PMCID: PMC3488724  PMID: 23075572
Paediatric Surgery
19.  Manual small incision cataract surgery under topical anesthesia with intracameral lignocaine: Study on pain evaluation and surgical outcome 
The authors here describe manual small incision cataract surgery (MSICS) by using topical anesthesia with intracameral 0.5% lignocaine, which eliminates the hazards of local anesthesia, cuts down cost and time taken for the administration of local anesthesia.
Aims
To evaluate the patients' and surgeons' experience in MSICS using topical anesthesia with intracameral lignocaine in terms of pain, surgical complications, and outcome.
Settings and Design
Prospective interventional case series.
Materials and Methods
Ninety-six patients of senile cataract were operated by MSICS under topical anesthesia with intracameral lignocaine using “fish hook technique.” The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience, and complications.
Statistical Analysis Used
Statistical analysis software “Analyseit.”
Results
There were 96 patients enrolled in the study. The mean pain score was 0.7 (SD ± 0.97, range 0–5, median 0.0, and mode 0.0). Fifty-one patients (53%) had pain score of zero, that is, no pain. Ninety-one patients (˜95%) had a score of less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon's experience was favorable in terms of patient's cooperation, anterior chamber stability, difficulty, and complications. The ocular movements were not affected, and hence, the eye patch could be removed immediately following the surgery.
Conclusions
MSICS can be performed under topical anesthesia with intracameral lignocaine, which makes the surgery patient friendly, without compromising the outcome.
PMCID: PMC2661525  PMID: 19075400
Anesthesia; intracameral lignocaine; pain evaluation; manual small incision cataract surgery; topical
20.  Real-time observations of stressful events in the operating room 
Saudi Journal of Anaesthesia  2012;6(2):136-139.
Aim:
To identify and quantify factors causing stress in the operating room (OR) and evaluate the relationship between these factors and surgeons’ stress level.
Methods:
This is a prospective observational study from 32 elective surgical procedures conducted in the OR of King Khalid University Hospital, Riyadh, Saudi Arabia. Before each operation, each surgeon was asked of stressors. Two interns observed 16 surgeries each, separately. The interns watched and took notes during the entire surgical procedure. During each operation, the observer recorded anxiety-inducing activities and events that occurred in real time by means of a checklist of 8 potential stressors: technical, patient problems, teamwork problems, time and management issues, distractions and interruptions, equipment problems, personal problems, and teaching. After each operation, surgeons were asked to answer the validated State-Trait Anxiety Inventory questionnaire and self-report on their stress level from the 8 sources using a scale of 1–8 (1: stress free, 8: extremely stressful). The observer also recorded perceived stress levels experienced by the surgeons during the operation.
Results:
One hundred ten stressors were identified. Technical problems most frequently caused stress (16.4%) and personal issues the least often (6.4%). Frequently encountered stressors (teaching and distractions/interruptions) caused less stress to the surgeons. Technical factors, teamwork, and equipment problems occurred frequently and were also a major contributor to OR stress. All patients were discharged in good health and within 1 week of surgery.
Conclusion:
Certain stressful factors do occur among surgeons in the OR and can increase the potential for errors. Further research is required to determine the impact of stress on performance and the outcome of surgery.
doi:10.4103/1658-354X.97026
PMCID: PMC3385255  PMID: 22754439
Operating room; stressful events; surgeon
21.  Computer-assisted functional endoscopic sinus surgery (c-a fess) — a review 
CT and MR imaging give spatial information of patient’s disease and anatomy. They help in preoperative surgical planning and guide the surgeon during operation. In conventional Functional Endoscopic Sinus Surgery (FESS), surgeon mentally correlates the information of CT and MR with the direct sinuscopic view of operative field. In Computer-Assisted Functional Endoscopic Sinus Surgery ( C-A FESS), computer provides image guidance for the surgeon. Surgeon can appreciate ike immediate surrounding structures outside the direct endoscopic vision of the surface. Thus widely enhancing the field of endoscopic mage. The overall accuracy of 1 to 2 mm has been reported. Many systems of tracing are being developed and tested far. Each system has its own advantages and disadvantages. It is now possible to guide mrgery with intraoperatively acquired MR images. The real-time imaging shows the tissue changes occurring during the operation. Surgeon can safely operate the lesions of optic nerve, sphenoid sinuses, pituitary gland, and cranial base.
doi:10.1007/BF03006217
PMCID: PMC3451091  PMID: 23119709
Computer-Assisted Surgery; Computer-Aided Surgery; Computer-Augmented Surgery; Image-Guided Surgery; Functional Endoscopic Sinus Surgery; Endoscopic Sinus Surgery
22.  Preoperative and Postoperative Nomograms Incorporating Surgeon Experience for Clinically Localized Prostate Cancer 
Cancer  2009;115(5):1005-1010.
BACKGROUND
Accurate preoperative and postoperative risk assessment has been critical for counseling patients regarding radical prostatectomy for clinically localized prostate cancer. In addition to other treatment modalities, neoadjuvant or adjuvant therapies have been considered. The growing literature suggested that the experience of the surgeon may affect the risk of prostate cancer recurrence. The purpose of this study was to develop and internally validate nomograms to predict the probability of recurrence, both preoperatively and postoperatively, with adjustment for standard parameters plus surgeon experience.
METHODS
The study cohort included 7724 eligible prostate cancer patients treated with radical prostatectomy by 1 of 72 surgeons. For each patient, surgeon experience was coded as the total number of cases conducted by the surgeon before the patient’s operation. Multivariable Cox proportional hazards regression models were developed to predict recurrence. Discrimination and calibration of the models was assessed following bootstrapping methods, and the models were presented as nomograms.
RESULTS
In this combined series, the 10-year probability of recurrence was 23.9%. The nomograms were quite discriminating (preoperative concordance index, 0.767; postoperative concordance index, 0.812). Calibration appeared to be very good for each. Surgeon experience seemed to have a quite modest effect, especially postoperatively.
CONCLUSIONS
Nomograms have been developed that consider the surgeon’s experience as a predictor. The tools appeared to predict reasonably well but were somewhat little improved with the addition of surgeon experience as a predictor variable.
doi:10.1002/cncr.24083
PMCID: PMC3391599  PMID: 19156928
prostate cancer; surgeon experience; recurrence; predictive value; nomogram
23.  The role of case mix in the relation of volume and outcome in phacoemulsification 
The British Journal of Ophthalmology  2005;89(9):1143-1146.
Background/aim: The authors previously demonstrated a decrease in complication rate with an increase in volume of cases performed by a surgeon. All studies of volume and outcome are potentially hampered by the issue of case mix, in that some lower volume surgeons may in fact do fewer cases because they have more complex patients. This study was designed to assess the influence of case mix on the volume-outcome relation in phacoemulsification surgery that had previously been demonstrated.
Methods: This study took place wholly in Sunderland Eye Infirmary. 667 cases from between 1996 and 2001 were randomly selected from the operative lists of the six surgeons involved in a previous study. The case complexity was assessed using a potential difficulty score (PDS) devised from preoperative data predictive of potential surgical difficulty. The PDS was validated by a retrospective analysis of a sample of 100 cases.
Results: 528 complete sets of notes were retrieved. The overall PDS scores ranged from 1 to 6. There was a difference between the proportions of patients with each PDS value (p = 0.015) in the two groups, which suggested that the low volume surgeons were doing potentially more difficult cases. The median PDS for each volume group were the same ( = 1.0). Retrospective validation analysis of the PDS score revealed higher mean and median values in complicated cases compared to uncomplicated cases.
Conclusion: This follow up study re-emphasises the importance of case mix adjustment in comparative assessment of healthcare quality. These results may explain in part the trend previously demonstrated of lower complication rates for higher volume surgeons.
doi:10.1136/bjo.2005.070235
PMCID: PMC1772833  PMID: 16113369
phacoemulsification; case mix; difficulty score; volume-outcome relation
24.  Breast Reduction Surgery in the UK and Ireland–Current Trends 
INTRODUCTION
This paper reviews the current status of bilateral breast reduction surgery in the UK and Ireland. It examines the pre-operative, operative and postoperative management of women.
PATIENTS AND METHODS
A questionnaire established information about surgeons' experience, bilateral breast reduction work-load, pre-operative assessment, selection criteria, issues of operative technique and postoperative management. This was sent to 230 consultant plastic surgeons working in the NHS in the UK and Ireland.
RESULTS
There was a 61% response rate. Of respondent surgeons, 82% always perform pre-operative photography, 71% never do a mammogram even in patients above the age of 50 years. Body mass index (BMI) is the most commonly used criteria for patient selection (60%). Two-thirds of the surgeons use an inferior pedicle technique and 75% of surgeons work in health authorities that restrict breast reduction surgery.
CONCLUSIONS
There was significant variation in practice among surgeons performing bilateral breast reduction. This may reflect a lack of evidence base for practise. Published literature focuses almost exclusively on the description of different techniques. Further work is required to evaluate the role of pre-operative mammography, specimen mammography, antibiotics and selection criteria for surgery.
doi:10.1308/003588406X130598
PMCID: PMC1963764  PMID: 17059724
Bilateral breast reduction; Audit; Pre-operative assessment; Selection criteria; Operative technique; Postoperative management
25.  Correlation between clinical diagnosis and arthroscopic findings of the shoulder 
Postgraduate Medical Journal  2005;81(960):657-659.
Objective: To assess the accuracy of clinical examination by non-specialist orthopaedic surgeons of patients presenting to a diagnostic and treatment centre (DTC) for arthroscopic shoulder surgery.
Methods: A retrospective review of notes of 130 consecutive shoulder arthroscopies performed at a DTC over a 10 month period. Preoperative clinical diagnosis was compared with operative arthroscopic findings. Additional information from preoperative imaging was compared with clinical examination and arthroscopic findings. Preoperative clinical examinations and consent were undertaken by clinical fellows, (SpR level) and non-upper limb consultant orthopaedic surgeons. Consultants specialising in upper limb surgery performed the operations.
Results: Six main groups were identified on the basis of clinical examination: impingement 76 cases (58%), instability 22 cases (17%), frozen shoulder 11 cases (8%), rotator cuff tear four cases (3%), non-specific pain eight cases (6%), and normal clinical examination nine cases (7%). Impingement and instability diagnosed clinically strongly correlated with the arthroscopic findings. Clinical diagnosis of frozen shoulder and rotator cuff tears had a weaker correlation with the arthroscopic findings. Of the nine cases of normal clinical examination, abnormality was found at arthroscopy in all cases.
Conclusion: There have been very few studies comparing clinical examination of the shoulder with arthroscopic findings. This study emphasises the importance of good clinical examination skills in diagnosing common shoulder abnormalities. The addition of imaging, particularly ultrasound and magnetic resonance imaging further increases the likelihood of an accurate diagnosis. Shoulder examination should be taught with as much emphasis at both undergraduate and postgraduate level as other orthopaedic clinical examinations.
doi:10.1136/pgmj.2004.030254
PMCID: PMC1743363  PMID: 16210463

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