PurposeAfrica bears 25% of the world's burden of surgical disease with only 3% of the global health workforce. Laparoscopy is now the standard approach for many surgical conditions and yet laparoscopic training remains mostly inaccessible to practicing surgeons in low- and middle-income African countries (LMICs). The goal of this study is to assess the efficacy of a low-cost, locally accessible laparoscopic skills course designed to meet the critical need in this region.MethodsALL-SAFE is a global surgical collaborative that designed a low-cost laparoscopy training system with modules simulating laparoscopic salpingostomy for ectopic pregnancy and laparoscopic appendectomy for appendicitis using locally accessible materials. A laparoscopic skills course was conducted by ALL-SAFE in a large tertiary-care hospital in Abuja, Nigeria, in October 2023. During the 2-day course, participants engaged in didactic lectures on the physiology and mechanics of laparoscopic surgery, practiced basic laparoscopic skills, observed two live laparoscopic cases, and completed the ALL-SAFE ectopic pregnancy and appendectomy simulated procedures on individual box trainers. Participants completed pre- and post-course surveys to assess their confidence in the knowledge and skills required for laparoscopic surgery.Results100% (n = 32) of the participants completed the pre-course survey and 71.9% (n = 23) completed the post-course survey. Course participants were mostly male (81.3%, n = 26), while 46.9% (n = 15) were general surgeons, 25% (n = 8) were urologists, and the remaining represented other surgical subspecialties. While most participants reported that they had access to a laparoscopic tower at their hospital (93.8%) and they had previously observed laparoscopic cases (62.5%), 50% (n = 16) said that this ALL-SAFE course was their first exposure to laparoscopic simulation. Prior to the course, 46.9% of participants felt "not at all confident" and 37.5% felt "slightly confident" in performing a laparoscopic appendectomy. Following the course, 39.1% of participants felt "very confident" and 34.8% felt "moderately confident". All participants felt that they were successful in achieving their educational goals for the course (17.4% moderately successful, 56.5% very successful, 26.1% extremely successful).ConclusionA short laparoscopy training course using a low-cost platform was successful at improving confidence in performing laparoscopic surgery and achieving the educational goals of a diverse group of Nigerian surgeons. Hosting similar courses in other African LMICs may improve dissemination of laparoscopic surgical skills in this region.

Presidential address delivered at the 2024 Annual meeting of the Midwest Surgical Association, Mackinac Island, MI on August 6th 2024

Background: Review of multiple casualty events (MCEs) protocols in an academic trauma center and more importantly role of residents in management of MCEs has not been discussed. Also, no real-world examples have been described. This study reviews utilization of multiple casualty protocols by the area hospitals and EMS along with role of residents in one such real-world MCEMethods: A mass shooting event in the Oregon District in Dayton, Ohio from 2019 was reviewed. MCE protocols from a Level I trauma center were reviewed as well as patient outcomes and role of residents.Results: A total of 10 casualties were observed and 38 patients presented to hospitals throughout the city. There were 25 patients presented to the Level I trauma center, 1 to the Level II trauma center, and 12 to the Level III trauma centers in the community. Surgical and Emergency residents performed initial triage upon arrival to the ED, managed resuscitation, and performed various procedures under supervision of attending staff. A total of 5 patients required emergent surgery and 4 patients required tourniquets. All patients that were presented to the hospitals survived.Conclusion: MCEs are going to continue, and healthcare systems should have protocols in place. Residents are a valuable resource to hospital systems that provide trauma services. Creation of a protocol with the assistance of EMS will allow first responders to utilize resources available. We recommend testing of this protocol, as an MCE in your area may not be a matter of if, but when.

INTRODUCTION:Splenic artery embolization (SAE) is a routinely used adjunct in the nonoperative management (NOM) of blunt splenic injury (BSI). The purpose of this study was to evaluate the rate and type of adverse events that occur in patients undergoing SAE and to compare this with the previous data. METHODS:Patients who had SAE for BSI between 2011 and 2018 were identified. Splenic abscess, splenic infarction, and contrast-induced renal insufficiency were considered major complications. Coil migration, fever, and pleural effusions were regarded minor complications. The results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010. RESULTS:There were 716 patients admitted with BSI. SAE was performed in 74 (13.3%) of the 557 (78%) NOM patients. The overall complication rate was 33.8%. Major complications occurred in 11 patients (14.9%) and minor in 13 patients (18.9%). There was no association between complications and coil location by logistic regression. CONCLUSIONS:SAE continues to be a useful adjunct in the NOM of BSI though complications continue to occur. Fewer minor complications were noted in the period studied compared to past similar studies.

BACKGROUND:Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients.METHODS:Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices.RESULTS:A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30.CONCLUSION:The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing.LEVEL OF EVIDENCE:Diagnostic test, level II.

BACKGROUND:In laparoscopic appendectomy (LA), closure of the appendiceal stump can be achieved using either an endostapler or endoloop. We compared outcome data from utilizing either technique.METHOD:Data was collected for all adult patients who underwent LA for appendicitis at a single institution over a 4-year period. Demographic data, complications, length of stay and hospital charges were compared between both groups.RESULTS:A total of 501 patients underwent LA in the 4-year period. There were no differences in age, gender or BMI. Additionally, there were no differences in procedure length, readmission rates, complication rates (including intra-abdominal abscess) or hospital charges. There was a slightly shorter length of stay in the endoloop closure group (1.22 days) vs endostapler (1.38 days), p = 0.002.CONCLUSION:Neither technique of appendiceal stump closure demonstrated a unique advantage. These findings may have relevance in low resource environments that may not have routine access to surgical staplers.

Objectives To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis. Background The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the two procedures. Methods Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from four centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary endpoint was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary endpoints as well as a decreasing accrual rate. Results Patient demographics were equally distributed in both groups (Hinchey III: 76% vs. 75% and Hinchey IV: 24% vs. 25%, for HP vs. PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs. 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs. 9% and morbidity 67% vs. 75% in HP vs. PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs. 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs. 20%, P = 0.046), operating time (73 minutes vs. 183 minutes, P < 0.001), hospital stay (6 days vs. 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs. US $24,014) were significantly reduced in the PA group. Conclusions This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

OBJECTIVE:Proper use of automobile seat belt in a motor vehicle crash is associated with reduced morbidity and mortality, shorter hospital stays, reduced resource utilization, and fewer missed work days. Seatbelt compliance nationwide is 86%. This study was undertaken to identify factors associated with noncompliance with seatbelt use among admitted patients following a motor vehicle crash. METHODS:This study was a retrospective analysis of motor vehicle crashes at an Urban Level 1 Trauma Center. Eligible subjects included patients age 18 and over, who were admitted by the Trauma Service following a motor vehicle crash from January to December 2017. RESULTS:Among 766 participants, the overall rate of seatbelt noncompliance was 32% (N = 245). Some participants met the legal limit of intoxication (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this population, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphetamine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs. 24.2%), and methamphetamine (15.6% vs. 5.9%). We did not detect significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use. CONCLUSIONS:In this study, 32% of patients in motor vehicle crashes were not compliant with seat belt use. Noncompliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine.

Road traffic injuries are the most common form of trauma, prompting patients to seek health care. Fractures of the pelvic ring may cause severe injuries, including to the genitourinary system and few sustain injury to the bladder. Bladder rupture may be intraperitoneal (IP), extraperitoneal (EP), or both; the location determines injury management strategy. IP rupture results when a distended bladder extends above the brim of the pelvis, exposing it to abdominal shearing forces, whereas EP rupture is associated with crushing blunt forces exerted by the anterior pelvis or bony fragments puncturing the lower portion of the bladder.1 IP bladder rupture is typically managed operatively to prevent extravasation of urine into the peritoneal cavity, which may result in peritonitis, sepsis, and death.2 The treatment of EP bladder rupture is controversial, with current guidelines recommending most be managed by catheter drainage. Those prompting surgical interventions are injuries to the bladder neck1 and to areas nearby orthopedic hardware2 to reduce the likelihood of infection.3 We investigated whether surgical repair or conservative management with catheter drainage resulted in a lower rate of contrast extravasation on follow-up cystogram in patients with concomitant traumatic EP rupture and pelvic fracture. All patients with concomitant EP bladder rupture and pelvic fracture admitted to a Level 1 trauma center over a 16-year period were selected for the study. Figure 1 shows the injury pattern reviewed and treatment algorithm. Thirty-one of 41,940 patients who were admitted after blunt traumatic injury met these criteria. Data were abstracted from the trauma registry and chart review. These 31 patients included 27 with an EP bladder rupture and four with both IP and EP bladder rupture. Ten underwent operative repair (including those with IP and EP combined injuries), and as per urologist preference, 21 had nonoperative treatment. All patients had their injuries documented with abdominal and pelvic CT scans with bladder contrast. Variables that were collected are depicted in Table 1. Means and SDs were reported for continuous variables, and counts and per cents for categorical variables. For the independent samples, Mann-Whitney test, the chi-squared test, and Fisher’s exact Test were used for comparisons. Inferences were made at the 0.05 level of significance. Table 1 shows that the bladder surgical repair group and the conservative management group did not differ on age (36.3 ± 20.9 vs 40.6 ± 16.7 years, P4 0.39) or gender (70% male vs 48% male, P 4 0.43). The two groups did not differ on Injury Severity Score (25 ± 11.3 vs 27.7 ± 9.3, P4 0.63) or Revised Probability of Survival Score (0.81 ± 0.28 vs 0.69 ± 0.35, P4 0.49). Also, the two groups did not differ on the orthopedic trauma fracture code (60% open book fractures vs 43%, P 4 0.61) or American Association for the Surgery of Trauma (AAST) bladder classification (P 4 0.57). Thirteen EP bladder ruptures were less than 2 cm, nine were greater than 2 cm, and nine were to the neck or trigone. Conservative management was used on 77 per cent of the <2 cm ruptures and 75 per cent of the >2 cm ruptures (P 4 1.00). The proportion with bladder extravasation on follow-up cystogram was similar for the two groups (surgical repair 4 40% vs conservative management 4 38%, P 4 1). Five of nine (56%) EP bladder ruptures greater than 2 cm leaked, and 2 of 13 (15%) less than 2 cm leaked [P4 0.07]. Open book and closed pelvic fractures did not differ in the likelihood of bladder leakage (47% vs 31%, P4 0.38). ICU length of stay (LOS) was six days longer for the bladder surgical repair group (13.1 ± 13.7 vs 7.1 ± 10.3), but small sample sizes and large SDs resulted in the difference not being statistically significant (P 4 0.16). However, the nearly seven-day difference for hospital LOS (21.4 ± 11.5 vs 14.5 ± 12.4) was marginally significant (P 4 0.06); there was one death in each group. This study is one of few examining treatment strategies for EP bladder ruptures in trauma patients, specifically Address correspondence and reprint requests to Alison M. Bales, M.D., Department of General Surgery, Indiana University Health, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN 45202. E-mail: alison.m.bales@gmail.com.

Estimating the prevalence of harassment, verbal abuse, and discrimination among residents is difficult as events are often under-reported. The purpose of this study was to determine the prevalence of discrimination and abuse among surgical residents using the HITS (Hurt, Insulted, Threatened with harm or Screamed at) screening tool. A multicenter, cross-sectional, survey-based study was conducted at five academic teaching hospitals. Of 310 residents, 76 (24.5%) completed the survey. The HITS screening tool was positive in 3.9 per cent. The most common forms of abuse included sexual harassment (28.9%), discrimination based on gender (15.7%), and discrimination based on ethnicity (7.9%). There was a positive correlation between individuals who reported gender discrimination and racial discrimination (r = 0.778, n = 13, P = 0.002). Individuals who experienced insults were more likely to experience physical threats (r = 0.437, n = 79, P < 0.001) or verbal abuse (r = 0.690, n = 79, P < 0.001). Discrimination and harassment among surgical residents in academic teaching hospitals across the United States is not uncommon. Further research is needed to determine the impact of these findings on resident attrition.

Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.

Subarachnoid hemorrhage (SAH) results frequently from traumatic brain injury (TBI). The standard management for these patients includes brief admission by the acute care surgery (trauma) service with neurological checks, neurosurgical consultation and repeat head CT within 24 hours to identify any progression or resolution. Recent studies have questioned the need for repeat CT imaging and specialty consultation in mild TBI. We reviewed patients with mild TBI specifically with isolated SAH to determine progression of the pathology and need for neurosurgical involvement. All patients with SAH secondary to mild TBI (Glasgow Coma Score (GCS) of 13–15) who presented over a 5-year period (January 2010 to December 2014) to a level I trauma center were identified from the trauma registry. Demographic data, initial CT findings, neurosurgical consultation, follow-up CT findings, Injury Severity Score (ISS), admission GCS and length of stay (LOS) were all obtained from the patient’s charts. Patients with other traumatic brain lesions on the initial CT were excluded. There were 299 patients (male, 48.5%), mean age 60.9 and mean ISS 8. Average time between the first and second CT was 11.3 hours. In all, 267 (89.2%) patients had either no change or an improvement/resolution on follow-up CT scan. Only 26 patients (8.7%) had either worsening or new findings on CT. Eight patients did not have a second scan completed (2.6%). All patients had neurosurgical consultation. Patients with mild TBI with isolated SAH generally have low morbidity, short LOS and negligible mortality. Less than 10% of this population had worsening of their head injury on repeat CT scanning. Given the low acuity of these patients with SAH and tendency towards resolution without intervention, acute care surgeons can manage this specific group of patients with TBI without routine neurosurgical consultation. Repeat CT scanning continues to have utility as it may identify new lesions, deterioration or need for further management.

Case summary A 33-year-old woman was transferred from an outside hospital with a penetrating injury to her right chest. The patient was shot with a crossbow with the entry site to the right breast/chest and a transmediastinal trajectory. She was intubated prior to arrival due to difficulty breathing. Her vital signs remained stable and within normal limits, with good breath sounds, and no evidence of pneumothorax on chest X-ray. The tip of the bolt was palpable at the patient’s left midaxillary line. Chest X-ray in trauma bay showed the transmediastinal trajectory, and the bolt appeared to have a field point (not a broadhead point) (figure 1). A CT of the chest was obtained to assist with surgical planning. Images showed the bolt penetrating the right chest, right ventricle and inferior aspect of the left ventricular muscle, through the stomach, and ending near the tip of the spleen with a fracture of the left seventh rib (figure 2). Figure 1 Image A shows the bolt (crossbow arrow) entering the patient’s right breast and chest. Image B is the chest X-ray taken in the trauma bay showing the transmediastinal trajectory and partial visualization of the tip of the bolt with a field point. Image C demonstrates the tip of the bolt after removal. Figure 2 CT of the chest with intravenous contrast showing a foreign body penetrating the right chest at the fourth intercostal space, right ventricle, left ventricle muscle, left hemidiaphragm, through the stomach, and ending near the tip of the spleen without injury to it. There was also a fracture of the lateral seventh rib and hemopericardium. The tip of the bolt is not clearly demonstrated due to artifact. What would you do? Median sternotomy followed by midline laparotomy. Clamshell thoracotomy in the Emergency Room (ER). Right anterolateral thoracotomy. Left posterolateral thoracotomy.

Background The Acute Care Surgery (ACS) model developed during the last decade fuses critical care, trauma, and emergency general surgery. ACS teams commonly perform laparoscopic cholecystectomy (LC) for acute biliary disease. This study reviewed LCs performed by an ACS service focusing on risk factors for complications in the emergent setting. Methods All patients who underwent LC on an ACS service during a 26-month period were identified. Demographic, perioperative, and complication data were collected and analyzed with Fisher’s exact test, χ2 test, and Mann-Whitney U Test. Results During the study period, 547 patients (70.2% female, mean age 46.1±18.1, mean body mass index 32.4±7.8 kg/m2) had LC performed for various acute indications. Mean surgery time was 77.9±50.2 minutes, and 5.7% of cases were performed “after hours.” Rate of conversion to open procedure was 6%. Complications seen included minor bile leaks (3.8%), infection (3.8%), retained gallstones (1.1%), organ injury (1.1%), major duct injury (0.9%), and postoperative bleeding (0.9%). Statistical analysis demonstrated significant relationships between conversion, length of surgery, age, gender, and intraoperative cholangiogram with various complications. No significant relationships were detected between complications and BMI, pregnancy, attending experience, and time of operation. Discussion Although several statistically significant relationships were identified between several risk factors and complications, these findings have limited clinical significance. Factors including attending years in practice and time of the operation were not associated with increased complications. ACS services are capable of performing a high volume of LCs for emergent indications with low complication and conversion rates. Level of evidence:IV

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

The significance of delineating goals of care (GoC) for geriatric patients has been well known to the palliative care community but is a relatively new concept to burn surgeons. We surveyed palliative care specialists (PCS) and burn surgeons (BS) to elicit their attitudes regarding: 1) the importance of goal setting for burned seniors; 2) each specialty’s confidence in their own ability to conduct GoC conversations; and 3) their confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multi-center consortium dedicated to palliative care in the burned geriatric patient. The instrument draft was sent to burn and palliative care providers unaffiliated with the consortium for beta-testing. The finalized instrument was electronically circulated to all active physician members of the American Burn Association (ABA) and the American Academy for Hospice and Palliative Medicine (AAHPM). Surveys underwent review and approval by the research committees of each organization. Responses were received from 45 subjects categorized as BS (7.3%) and 244 PCS (5.7%). PCS rated being more familiar with GoC, were more comfortable having a GoC discussion with laypeople, were more likely to have reported high quality training in performing GoC conversations, believed more palliative care physicians were needed in ICUs, and had more interest in conducting GoC conversations relative to BS. Interestingly, both sets of physicians believed themselves to perform GoC discussions better than their peers perceived them to do so. In regard to perceptions of the best model for conducting GoC discussions, BS favored leading team discussions, where PCS endorsed both PCS and BS led discussions. Both also generally agreed that GoC discussions should occur with 72 hours of admission. PCS were more likely to have reported training in determining GoC in fellowship and on-the-job training, have fewer years of experience in their specialty, and less frequently deliver care to burned seniors relative to BS. Regarding work setting, BS reported working predominantly in academic private centers and academic safety net hospitals, and PCS representing a wider array of contexts. Both BS and PCS believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions on the optimal leadership of these discussions. A dichotomy of views regarding the roles and responsibilities of BS and PCS in the conduct of GoC discussions for burned seniors highlights the need for future work to inform best practices.