PURPOSE:United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) scores have been predictive of performance on in-training examinations in various fields, including internal medicine and surgery. As of 2022, USMLE Step 1, a basic science examination that has been studied as a strong predictor of Step 2 CK scores, has transitioned to pass/fail grading. This study aims to identify factors that predict performance on the Step 2 exam, focusing on comparisons with prior standardized test scores. METHOD:In this single-institution cross-sectional study, data from 600 medical students at the University of California San Francisco who matriculated between 2016 and 2019 were analyzed. Scores on the Medical College Admission Test (MCAT), Comprehensive Basic Sciences Examination (CBSE), Open-Ended Question (OEQ) in-house block exams, and National Board of Medical Examiners (NBME) subject examinations were collected. There were 12 OEQ exams taken during the preclinical foundational science blocks. Multivariable regression models were used to examine MCAT, CBSE, OEQ, and NBME subject exam score predictability of Step 2 CK score. Data were analyzed in February 2023. RESULTS:A model containing the MCAT combined percentile, CBSE 1, CBSE 2, NBME subject exams for neurology, psychiatry, and surgery, and in-house block examinations for five different blocks accounted for 45% of variability in Step 2 score. The surgery NBME subject exams had the largest β coefficient (β = 0.212, P < .001). This study found that neurology, psychiatry, and surgery NBME exam scores are the strongest predictors of Step 2 performance. CONCLUSIONS:In students who may be underperforming, these findings promote earlier interventions to optimize standardized test scores, which, with a well-rounded curriculum vitae, maximize chances of successful residency match.

To compare outcomes of robotic and open repair for uncomplicated, moderate-sized, midline ventral hernias. From 2017 to 2021, patient characteristics and 30 day outcomes for all ventral hernias at our center were prospectively collected. We studied hernias potentially suitable for robotic repair: elective, midline, 3–10 cm rectus separation, no prior mesh, and no need for concomitant procedure. Robotic or open repair was performed by surgeon or patient preference. The primary outcome was any complication using Clavien–Dindo scoring. Secondary outcomes were operative time, length-of-stay, and readmissions. Regression identified predictors of complications. Of 648 hernias repaired, 70 robotic and 52 open repairs met inclusion criteria. The groups had similar patient demographics, co-morbidities, and hernia size, except that there were more immunosuppressed patients in the open group (11 versus 5 patients, p = 0.031). Complications occurred after 7 (13

Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy. Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18 years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90 day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates. A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90 day readmission rates after laparoscopic cholecystectomy were 11.4

Purpose During the COVID-19 pandemic, virtual and alternative teaching strategies were developed with subsequent changes in the number of required didactic hours. However, the exact relationship between number of didactic hours and performance on the National Board of Medical Examiners (NBME) Subject Exams is not clear. This study aims to evaluate the impact of reduced didactic hours on medical student NBME performance during the third-year surgery clerkship. Methods This retrospective study evaluated the first-time pass rates and mean scores on the NBME exam for medical students who participated in an eight-week surgery clerkship at a single institution between 2017 and 2022. Didactic schedules, including hours of synchronous and asynchronous content, and de-identified scores were obtained. Analysis of Variance (ANOVA) test, chi-squared test, linear regression, and logistic regression were used to assess for differences in scores and pass rates as a function of didactic hours. Results The cohort included 964 students. The mean NBME score was 72.23 and differed significantly across didactic hours ( p < 0.001). Compared to students who received 15 didactic hours, those who received 25.5, 33, and 37 h had 2.93 ( p = 0.01), 3.44 ( p = 0.004), and 2.41 ( p = 0.049) times odds of failing, respectively. Conclusions Increased didactic hours during surgery clerkships was not associated with higher NBME scores or first-time pass rates. Reducing didactic hours may improve exam performance and allow students more independent study time while decreasing faculty burden. Future research should seek to understand how reduced hours impacts students’ subjective experience and well-being.

BACKGROUND:The growing adoption of robotic-assisted surgery mandates residents must acquire robotic skills. No standardized curriculum for robotic surgery exists. Therefore, programs have developed their own curricula, which are often unstructured and based on resource availability. With this strategy programs may not adhere to scholarly approaches in curriculum development. We aimed to obtain a multi-institutional needs assessment to address training needs and identify integral components of a formalized robotic surgery curriculum. METHODS:A 10-question survey was distributed to general surgery residents. A separate 7-question survey was sent to robotic faculty surgeons at 3 institutions. Survey questions queried demographics, opinions regarding robotic training, proficiency definitions, and identification of procedures and instructional strategies for a curriculum. Mann- Whitney U test and Fisher's exact test were performed to compare responses amongst residents and faculty. Spearman's correlation was used to identify relationships between experience or post-graduate year (PGY) with response selection. RESULTS:Both residents and faculty believed robotic training should start in the PGY1 (55.1% vs 52%; p = 0.58). Faculty recognized robotic training to be more important compared to residents (84% vs 58.1%; p < 0.05). Both groups considered a minimum of 21 to 40 robotic cases to be sufficient exposure during training (p = 0.30). Cholecystectomy (82.4% vs 72%; p = 0.261), ventral hernia repair (89.2% vs 88%; p = 1.0), inguinal hernia repair (91.9% vs 92%; p = 1.0), and right colectomy (83.8% vs 80%; p = 0.7) were considered to be the most appropriate robotic procedures during training. Both groups concurred that bedside (91.9% vs 100%; p = 0.33) and console skills training (97.3% vs 100%; p = 1.0), small group simulation (94.6% vs 72% p = 0.005), and independent practice (87.8% vs 92% p = 0.73), were instructional strategies vital to a curriculum. Faculty considered online didactic modules (96% vs 59.5%; p < 0.05) to be more important, whereas residents favored small group experiences for fundamental skills (94.6% vs. 72%; p < 0.05) and procedure-based simulation (96% vs 64%; p < 0.05). CONCLUSIONS:Our targeted needs assessment identified requisite components of a robotics curriculum, which are feasible and accepted by both residents and faculty. Medical educators can use this as a resource to develop a formal robotics training curriculum.

Introduction: This study describes perceived knowledge gaps of third-year medical students after participating in a virtual surgical didactic rotation (EMLR) and shortened in-person surgery rotation during the COVID-19 Pandemic. Methods: Open-ended and Likert questions were administered at the end of the virtual rotation and inperson-surgical rotation to medical students. Three blinded coders identified themes by semantic analysis. Results: 82 students (51% of all MS3s) participated in the EMLR. Semantic analysis revealed gaps in perioperative management (Post-EMLR:18.4%, Post-Inpatient:26.5%), anatomy (Post-EMLR:8.2%, PostInpatient:26.5%). and surgical skills (Post-EMLR: 43.0%, Post-Inpatient: 44.1%). Students also described gaps related to OR etiquette (Post-EMLR: 12.2%, Post-Inpatient: 8.8%) and team dynamics/the hidden curriculum (Post- Inpatient:26.6%). There was a significant improvement in perceived confidence to perform inpatient tasks after completing the inpatient clinical experience (p <= 0.01). Conclusion: Virtual interactive didactics for cognitive skills development cannot replace a full clinical surgical experience for third-year medical students. Future curricula should address perceived gaps.

The hidden curriculum of unspoken professional expectations negatively impacts medical student interest in surgery. Medical student mentorship and early surgical exposure have been shown to demystify the hidden curriculum. Although residents and faculty play a vital role, near-peer mentorship may aid in uncovering the hidden curriculum and promoting medical student interest in surgery, especially for those learners who are underrepresented in medicine. We developed and implemented a formalized near-peer mentorship program composed of quarterly small group Surgical Peer Teacher led lessons and one-on-one Surgical Support Team mentorship meetings covering surgical curriculum topics for medical students at an academic medical school. This structured near-peer mentorship model provides a mechanism to demystify surgical culture, increase early access to surgical mentorship, and develop mentorship skills amongst students. This program aims to uncover the surgical hidden curriculum to improve surgical career support and interest among medical students with less exposure and access to physician role models. This longitudinal mentorship model is student-run and can be easily adapted to enhance existing support models at medical schools. Future studies will evaluate utilization, impact on surgical specialty interest, and efficacy in demystifying the surgical hidden curriculum.

OBJECTIVE:The aim of this study was to evaluate which mesh type yields lower recurrence and complication rates after ventral hernia repair.SUMMARY BACKGROUND DATA:More than 400,000 ventral hernia repairs are performed annually in the United States. Although the most effective method for repairing ventral hernias involves using mesh, whether to use biologic mesh versus synthetic mesh is controversial.METHODS:Single-blind, randomized, controlled, pragmatic clinical trial conducted from March 2014 through October 2018; 165 patients enrolled with an average follow up of 26 months. Patients were randomized 1:1 to have their ventral hernias repaired using either a biologic (porcine) or synthetic (polypropylene) mesh. The primary study outcome measure was hernia recurrence at 2 years.RESULTS:A total of 165 patients (68 men), mean age 55 years, were included in the study with a mean follow-up of 26 months. An intention-to-treat analysis noted that hernias recurred in 25 patients (39.7%) assigned to biologic mesh and in 14 patients (21.9%) assigned to synthetic mesh (P = 0.035) at 2 years. Subgroup analysis identified an increased rate of hernia recurrence in the biologic versus the synthetic mesh group under contaminated wound conditions (50.0% vs 5.9%; P for interaction = 0.041). Postoperative complication rates were similar for the 2 mesh types.CONCLUSIONS:The risk of hernia recurrence was significantly higher for patients undergoing ventral hernia repair with biologic mesh compared to synthetic mesh, with similar rates of postoperative complications. These data indicate that the use of synthetic mesh over biologic mesh to repair ventral hernias is effective and can be endorsed, including under contaminated wound conditions.TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT02041494.

INTRODUCTION: The impact of COVID-19 on surgical education has been profound, and clinical learning experiences transitioned to virtual formats. This study investigated the impact of virtual experiences created to facilitate learning during the pandemic for medical students. METHODS: We performed a cohort study to determine the perceived clinical preparedness for medical students enrolled in the preclinical surgery pilot course, surgical Extended Mastery Learning Rotation (EMLR), and longitudinal surgical clerkship (LC). The preclinical surgery pilot course took place before COVID-19 disruptions, and the EMLR and LC experiences took place virtually. Specialty choice was examined in the EMLR and LC cohorts. Performance on the NBME surgical assessments was analyzed among students enrolled in the traditional clerkship and pandemic-disrupted courses and compared to national data using a two-sample t-test. RESULTS: Compared to preclinical students, EMLR and LC students demonstrated improvements in their perceived surgical clerkship readiness. After the 3-week EMLR course, in the setting of completing only one-third of the clerkship year, students had an average NBME Surgical Self-Assessment Exam score of 72 (SD 12), comparable to the national average of 71 (SD 9) p = 0.33. The average shelf exam score for students (N = 24) enrolled in the traditional clerkship (block 1), prior to COVID-19, disruptions was 66 (SD 9) compared to an average score of 69 (SD 9) for the longitudinal clerkship students (N = 20) that took the shelf exam later in the year (p = 0.36). COVID-19 disruptions did not affect specialty choice. All LC students have decided on a specialty; 50% nonsurgical and 50% surgical. From the EMLR cohort, 36% and 38% plan to pursue surgical and nonsurgical specialties, respectively, with 26% still undecided. CONCLUSIONS: Courses were well-liked and will be implemented in future clerkships. Surgical educators demonstrated flexibility and creativity in the development of the EMLR. Despite COVID-19 disruptions, medical students made progress in their clinical skills and foundational science knowledge. COVID-19 disruptions did not appear to impact specialty choice. (C) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The longitudinal clerkship has been recognized as an innovative, unique model in medical education that demonstrates significantly higher student and preceptor satisfaction with comparable long-term outcomes like performance on standardized examinations. At the center of this model is the student-preceptor relationship, which promotes effective student-directed learning and personal and professional relationships with established faculty mentors. The University of California, San Francisco (UCSF) has two clerkships models: a traditional or "block" model consisting of 2-month sequential clinical rotations in seven core clerkships, and a longitudinal model that integrates parallel out-patient clinical experiences over the entire year with one-on-one faculty preceptors from each core discipline with focused 2-week intensive inpatient rotations. In the setting of the Covid-19 pandemic beginning in Spring of 2020, this arrangement allowed for a natural experiment to evaluate the resiliency of the respective models in the face of unprecedented disruptions in education and healthcare delivery. As described in this perspective, both clerkships required rapid pivots; however, students enrolled in the longitudinal clerkship were more likely to develop stronger relationships with surgical faculty and felt more prepared for making career choices. Medical school curricula may benefit from incorporating longitudinal components, as this model provided flexibility and fostered greater faculty-student mentorship in the setting of disruption to medical education.

The anxiety of starting clinical clerkships is high for third-year medical students (MS3s), who often have questions about topics not formally addressed in standard medical school curricula. The surgical clerkship may be one of the more stress-inducing experiences due to the paucity of contact with surgeons in the preclinical setting. 1 Nnamani O.N. Hernandez S.E. Sosa J.A. et al. The students have spoken: results from a preclinical surgical curriculum pilot. J Am Coll Surg. 2020; 231e202https://doi.org/10.1016/j.jamcollsurg.2020.08.539 Abstract Full Text Full Text PDF Google Scholar Lack of exposure may lead to preconceived notions that often drive student expectations at the start of the surgery clerkship. The literature demonstrates that MS3s express fears about fatigue, long hours, poor performance, and physical and mental hardships. 2 Pettitt B.J. Medical student concerns and fears before their third-year surgical clerkship. Am J Surg. 2005; 189: 492-496https://doi.org/10.1016/j.amjsurg.2004.09.017 Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Additionally, students have reported declining quality-of-life metrics during their surgery clerkship. 3 Goldin S.B. Wahi M.M. Farooq O.S. et al. Student quality-of-life declines during third year surgical clerkship. J Surg Res. 2007; 143: 151-157https://doi.org/10.1016/j.jss.2007.08.021 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Students are often unfamiliar with the intensity of the surgical workload, the team structure and function, and the general surgical culture. Some students may experience impostor syndrome, and may perceive mistreatment from other members of the surgical team; this is an issue for which many institutions have been in search of effective interventions. 4 Hasty B.N. Miller S.E. Bereknyei Merrell S. Lin D.T. Shipper E.S. Lau J.N. Medical student perceptions of a mistreatment program during the surgery clerkship. Am J Surg. 2018; 215: 761-766https://doi.org/10.1016/j.amjsurg.2018.01.001 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar However, these student experiences are not unique to the surgery clerkship. Overall, student perceptions of their general learning environment worsen during the transition from the safety of the preclinical classrooms to the realities of the patient care settings. 5 Dunham L. Dekhtyar M. Gruener G. et al. Medical student perceptions of the learning environment in medical school change as students transition to clinical training in undergraduate medical school. Teach Learn Med. 2017; 29: 383-391https://doi.org/10.1080/10401334.2017.1297712 Crossref PubMed Scopus (30) Google Scholar

OBJECTIVES:To investigate the performance and perspectives of third-year medical students (MS3s) participating in near-peer learning (NPL) sessions during their core surgical clerkship following a 15-month preclerkship curriculum. DESIGN:An evaluation study of 7 NPL sessions developed and implemented by fourth-year medical students (MS4s) held from March 2019 to February 2020. MS4s taught 1-2 sessions per rotation that included test taking strategies, illness script development, radiology review, case-based multiple-choice questions, and rapid review. Participants completed a questionnaire with 11 seven-point Likert and open-ended questions after each session. Analyses included quantitative comparison of shelf score averages between NPL participants and nonparticipants and qualitative content analysis for open-ended questions. SETTING:Surgical clerkship at the University of California, San Francisco. PARTICIPANTS:Forty-eight (32%) MS3s participated, with an average attendance of 10 students per rotation. Thirty-three (69%) participants completed the questionnaire. RESULTS:MS3s enjoyed the session (6.9 ± 0.4), improved their knowledge (6.8 ± 0.5), and felt more prepared for the surgery shelf examination (6.5 ± 0.6). MS4 leaders found that MS3s always wanted radiology review, and their interest in test taking strategies and illness script development declined across the clerkship year. Participants had lower shelf exam scores compared to nonparticipants (68.1 vs 71.4, respectively; p = 0.04, ES = 0.03). Shelf exam scores increased over time in both cohorts. Each group had 2 shelf exam failures. Qualitative analysis suggests that MS3s appreciated the NPL's tailored approach and exam demystification, with a desire for increased NPL integration into the clerkship. CONCLUSION:Students participating in NPL were satisfied with the sessions. Participants may have been students who struggled as indicated by shelf exam scores and appreciated the support. The shift in preferred topics across the blocks reflects the students' development during clerkships. Near-peer teachers should adjust sessions over time to fit students' evolving needs.

Background. Esophagogastroduodenoscopy (EGD) is an important tool in the evolving specialty of acute care surgery (ACS). Understanding the types of nonelective EGDs performed by ACS groups is important for the development of ACS programs and the training of future general surgeons. Methods. We conducted a retrospective review of all EGDs performed by ACS surgeons at a single urban academic center over a 5-year period (January 2013-December 2018). Results. A total of 495 EGDs were performed, of which 129 (26%) were urgent, nonelective procedures. Patients who underwent urgent EGD were younger than those who underwent elective procedures (median 55 vs 60 years,P=.03), had higher American Society of Anesthesiologists (ASA) classes (median ASA 3 vs 2, P=.0002), and longer hospital stays (median 5 days vs 0 days,P<.0001). The most common indications for urgent endoscopies were the management of leak, dysphagia, or stenosis in patients with a history of foregut surgery, followed by the management of esophageal perforation. The success rate of endoscopic therapy was high (median 88%, interquartile range (IQR) 78-89%). However, some patients required multiple interventions (median 1, IQR 1-3), and patients treated for leaks were less likely to be successfully treated with endoscopic therapy alone than patients treated for other indications (success rate 65% vs 88%, P=.003). Conclusions. Our experience suggests that EGD has an important role in current ACS practice and that endoscopic management is safe and effective in a range of urgent surgical scenarios. Future ACS surgeons should be facile with endoscopic techniques.

PURPOSE:Medical schools responding to challenges with fairness, equity, learning environments, and student wellness have reconsidered clerkship grades. This study used the Concerns-Based Adoption Model (CBAM) to explore how faculty responded to a change in the approach to assessment from focus on grades toward focus on feedback.METHOD:This qualitative study used an inductive approach to analyze data from semistructured interviews with teaching faculty and education leaders at University of California, San Francisco, School of Medicine 6 months following the elimination of traditional tiered clerkship grades. Participants were recruited in 2019 using purposive sampling. Interview questions addressed participants' perceptions of the new approach to assessment and grading that emphasizes assessment for learning, including advantages and concerns. The authors analyzed data using thematic analysis informed by sensitizing concepts from CBAM.RESULTS:Nineteen faculty participated (11 medicine, 8 surgery). Faculty expressed optimism about the impact of the change on their clinical educator roles and sought faculty development to enhance feedback and assessment skills. Perceived benefits to students addressed learning and wellness, with concern for students' motivation and professional development. Faculty shared uncertainty about their roles and larger systemic consequences involving the residency match and institutional reputation. Participants acknowledged that traditional grading is imperfect, yet felt a departure from this system represented significant culture change.CONCLUSIONS:Faculty perceptions of the assessment and grade change in 2 large departments demonstrated tensions around grading. Their descriptions of change as an ongoing process aligned with CBAM and required them to consider new approaches and perspectives. While discourse about assessment and grading frequently focuses on learners, these findings support institutional consideration of the impact of changes in assessment on teaching faculty.

PROBLEM:The COVID-19 pandemic has suspended the surgery clinical clerkship for third-year medical students at numerous institutions across the world. As a result, educators and students have adapted rapidly. There is a paucity of precedents regarding urgent and brusque formal curricular changes for medical students enrolled in surgical clinical rotations. APPROACH:The University of California, San Francisco Department of Surgery created a surgically focused extended mastery learning rotation (EMLR). The surgery clerkship leadership designed a curriculum consisting of multiple learning strategies compatible with virtual learning environments. The primary aims of the newly developed EMLR were to help students consolidate their foundational science knowledge before their return to clinical medicine in an altered learning environment. The EMLR is currently underway, and further studies are necessary to evaluate its effectiveness.

Nnamani, Ogonna N. BA; Hernandez, Sophia E. BS; Ann Sosa, Julie MD, MA, FACS; Lin, Matthew Y. MD, FACS; Campbell, Andre R. MD, FACS; Kim, Edward H. MD, FACS; Roman, Sanziana A. MD, FACS Author Information

Background: Gallstone disease occurs more commonly in the obese population and is often diagnosed during the preoperative evaluation for bariatric surgery. Objectives: This study analyzed outcomes of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (SG), with and without cholecystectomy (LC), using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Setting: Patients reported to Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers in the United States and Canada in 2015. Methods: All cases of LGB and SG, with and without LC, were analyzed. A 1:1 propensity-matched cohort was created for both SG and LGB, with and without concomitant LC. Multivariate logistic regression stratified by procedure was used to identify predictors of major complications after SG and LGB, using concomitant LC as a predictor. We also constructed a model for surgical site infections (SSIs) for SG group. Results: Of 98,292 sleeve operations, 2046 (2%) had concomitant LC. Of 44,427 bypass operations, 1426 (3%) had concomitant LC. For the sleeve group, concomitant LC increased operative time by an average of 27 minutes but did not affect length of stay, mortality, or major complications. Concomitant LC was associated with increased SSI (1% versus .4%) and need for reoperation (1.6% versus .7%) in univariate models. After adjusting for other predictors, concomitant LC was associated with increased risk for SSI (odds ratio 2.5, confidence interval 1.0-5.9, P = .04). For the bypass group, concomitant LC increased operative time by an average of 28 minutes to the operation, and postoperative length of stay averaged similar to 5 hours longer (2.4 versus 2.2 d, P = .03). Thirty-day complications were similar between the groups. On multivariate analysis, concomitant LC was not a significant risk factor for major complications. Only operative time was an independent factor for major complications. Conclusions: Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass did not affect mortality or risk of major complication. For sleeve patients, concomitant LC was associated with a .6% increased risk (.4% to 1.0%) of SSI. Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass is safe when indicated for gallstone disease. (C) 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.

BACKGROUND:Anterior exposures for lumbar spine surgery are increasingly common for treating various spinal pathologies. A retroperitoneal approach via a paramedian incision has grown rapidly in popularity, but little is known about the risk of incisional hernia development with this technique. We sought to assess the incidence of paramedian incisional hernia development and identify risk factors that are associated with occurrence. MATERIALS AND METHODS:We conducted a retrospective review of all patients who underwent anterior lumbar spine exposure by a paramedian approach between 2012 and 2017 at a single, tertiary medical center. The primary outcome was the development of postoperative paramedian incisional hernia. RESULTS:Of the 735 patients included in the study, 445 (60.5%) were women, and the mean (standard deviation) age of all patients was 60 y (12.4). Nearly all (97.4%) paramedian approaches were performed with a vascular surgeon present. Median follow-up time was 10 mo (interquartile range 3.5-19.9). Postoperative paramedian hernia developed in 20 patients (2.7%), of which 14 underwent repair. The mean (standard deviation) size of the hernia was 13.5 cm (5.5); 9 of 14 (64%) were repaired with synthetic mesh, whereas 3 of 14 (21%) required bowel resection. On multivariate analysis, risk factors associated with hernia development were male gender (0.045), higher American Society of Anesthesiologists class (0.039), history of abdominal surgery (P = 0.013), and postoperative intensive care unit admission (P = 0.02). CONCLUSIONS:A paramedian approach for anterior lumbar spine exposure resulted in a low rate of incisional hernia with minimal morbidity. Surgeons involved in these collaborative procedures should consider the risk factors that predispose patients to develop these hernias.

Left paraduodenal hernias are congenital internal hernias caused by the failure of the mesenteric and parietal peritoneum fusion with midgut malrotation. We present a case of a 22-year-old woman who presented with acute abdominal pain and was found to have a left paraduodenal hernia on CT. She underwent a laparoscopic reduction and primary repair of the defect. She presented two weeks later with acute abdominal pain and emesis and was taken emergently to the operating room after a CT showed a high-grade obstruction at the site of the prior hernia defect. In a laparoscopic converted to open exploration, several of the prior hernia closure’s sutures were removed and the bowel was released. This case highlights the importance of a perfect hernia closure, tight enough to prevent a recurrence but not too tight to cause an obstruction.

Purpose: The main purpose of this article is to compare capping and/or removal of cholecystostomy tubes to delayed cholecystectomy in patients who were not surgical candidates and underwent cholecystostomy tube placement for acute cholecystitis.