The SAGES Manual of Acute Care Surgery

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

D. Renton et al. (eds.)The SAGES Manual of Acute Care Surgeryhttps://doi.org/10.1007/978-3-030-21959-8_1

1. SAGES University MASTERS Program: Acute Care Pathway

Daniel B. Jones¹, ²  , Linda Schultz³ and Brian P. Jacob⁴

(1)

Office of Technology and Innovation, Minimally Invasive Surgical Services, Bariatric Program, Beth Israel Deaconess Medical Center, Boston, MA, USA

(2)

Harvard Medical School, Boston, MA, USA

(3)

Society of Gastrointestinal and Endoscopic Surgeons, Boston, MA, USA

(4)

Department of Surgery, Mount Sinai Health System, New York, NY, USA

Daniel B. Jones

Email: [email protected]

Keywords

Acute Care SurgeryMasters ProgramCompetencyProficiencyMasteryCoaching

Adopted from Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, Scott DJ. SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017;31(8):3061–71.

The Masters Program organizes educational materials along clinical pathways into discrete blocks of content which could be accessed by a surgeon attending the SAGES annual meeting or by logging into the online SAGES University (Fig. 1.1) [1]. The SAGES Masters Program currently has eight pathways including acute care, biliary, bariatrics, colon, foregut, hernia, flexible endoscopy, and robotic surgery (Fig. 1.2). Each pathway is divided into three levels of targeted performance: competency, proficiency, and mastery (Fig. 1.3). The levels originate from the Dreyfus model of skill acquisition [2], which has five stages: novice, advanced beginner, competency, proficiency, and expertise. The SAGES MASTERS Program is based on the three more advanced stages of skill acquisition: competency, proficiency, and expertise. Competency is defined as what a graduating general surgery chief resident or Minimally Invasive Surgery (MIS) fellow should be able to achieve; proficiency is what a surgeon approximately 3 years out from training should be able to accomplish; and mastery is what more experienced surgeons should be able to accomplish after several years in practice. Mastery is applicable to SAGES surgeons seeking an in-depth knowledge in a pathway, including the following areas of controversy, outcomes, best practice, and ability to mentor colleagues. Over time, with the utilization of coaching and participation in SAGES courses, this level should be obtainable by the majority of SAGES members. This edition of the SAGES Manual of Acute Care Surgery aligns with the current version of the new SAGES University MASTERS Program Acute Care Surgery pathway (Table 1.1).

Figure 1.1

MASTERS Program logo

Figure 1.2

MASTER Program Clinical Pathways

Figure 1.3

MASTERS Program Progression

Table 1.1

Acute Care Surgery curriculum

Acute Care Surgery Curriculum

The key elements of the Acute Care Surgery curriculum include core lectures for the pathway, which provide a 45-minute general overview including basic anatomy, physiology, diagnostic work-up, and surgical management. As of 2018, all lecture content of the annual SAGES meetings are labeled as follows: basic (100), intermediate (200), and advanced (300). This allows attendees to choose lectures that best fit their educational needs. Coding the content additionally facilitates online retrieval of specific educational material, with varying degrees of surgical complexity, ranging from introductory to revisional surgery.

SAGES identified the need to develop targeted, complex content for its mastery level curriculum. The idea was that these 25-minute lectures would be focused on specific topics. It assumes that the attendee already has a good understanding of diseases and management from attending/watching competency and proficiency level lectures. Ideally, in order to supplement a chosen topic, the mastery lectures would also identify key prerequisite articles from Surgical Endoscopy and other journals, in addition to SAGES University videos. Many of these lectures will be forthcoming at future SAGES annual meetings.

The MASTERS Program has a self-assessment, multiple-choice exam for each module to guide learner progression throughout the curriculum. Questions are submitted by core lecture speakers and SAGES annual meeting faculty. The goal of the questions is to use assessment for learning, with the assessment being criterion-referenced with the percent correct set at 80%. Learners will be able to review incorrect answers, review educational content, and retake the examination until a passing score is obtained.

The MASTERS Program Acute Care Surgery curriculum taps much of the of SAGES existing educational products including FLS, FUSE, SMART, Top 21 videos, and Pearls (Fig. 1.4). The Curriculum Task Force has placed the aforementioned modules along a continuum of the curriculum pathway. For example, FLS, in general, occurs during the Competency Curriculum, whereas the Fundamental Use of Surgical Energy (FUSE) is usually required during the Proficiency Curriculum. The Fundamentals of Laparoscopic Surgery (FLS) is a multiple-choice exam and a skills assessment conducted on a video box trainer. Tasks include peg transfer, cutting, intracorporeal and extracorporeal suturing, and knot tying. Since 2010, FLS has been required of all US general surgery residents seeking to sit for the American Board of Surgery qualifying examinations. The Fundamentals of Endoscopic Surgery (FES) assesses endoscopic knowledge and technical skills in a simulator. FUSE teaches about the safe use of energy devices in the operating room and is available at FUSE.​didactic.​org. After learners complete the self-paced modules, they may take the certifying examination.

Figure 1.4

SAGES Educational Content: FLS, FUSE, SMART

The SAGES Surgical Multimodal Accelerated Recovery Trajectory (SMART) Initiative combines minimally invasive surgical techniques with enhanced recovery pathways (ERPs) for perioperative care, with the goal of improving outcomes and patient satisfaction. Educational materials include a website with best practices, sample pathways, patient literature, and other resources such as videos, FAQs, and an implementation timeline. The materials assist surgeons and their surgical team with implementation of an ERP.

Top 21 videos are edited videos of the most commonly performed MIS operations and basic endoscopy. Cases are straightforward with quality video and clear anatomy.

Pearls are step-by-step video clips of ten operations. The authors show different variations for each step. Before viewing, the learner should have a fundamental understanding of the operation.

SAGES Guidelines provide evidence-based recommendations for surgeons and are developed by the SAGES Guidelines Committee following the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine standards (formerly the Institute of Medicine) for guideline development [3]. Each clinical practice guideline has been systematically researched, reviewed, and revised by the SAGES Guidelines Committee and an appropriate multidisciplinary team. The strength of the provided recommendations is determined based on the quality of the available literature using the GRADE methodology [4]. SAGES Guidelines cover a wide range of topics relevant to the practice of SAGES surgeon members and are updated on a regular basis. Since the developed guidelines provide an appraisal of the available literature, their inclusion in the MASTERS Program was deemed necessary by the group.

The Curriculum Task Force identified the need to select required readings for the MASTERS Program based on key articles for the various curriculum procedures. Summaries of each of these articles follow the American College of Surgeons (ACS) Selected Readings format.

Facebook™ Groups

While there are many great platforms available to permit online collaboration by user-generated content, Facebook™ offers a unique, highly developed mobile platform that is ideal for global professional collaboration and daily continuing surgical education (Fig. 1.5). The Facebook groups allow for video assessment, feedback, and coaching as a tool to improve practice.

Figure 1.5

Acute Care Facebook group

Based on the anchoring procedures determined via group consensus (Table 1.2), participants in the MASTERS Program will submit video clips on closed Facebook groups, with other participants and/or SAGES members providing qualitative feedback. For example, for the Acute Care Curriculum, surgeons would submit the critical views during a laparoscopic appendectomy. Using crowdsourcing, other surgeons would comment and provide feedback.

Table 1.2

Anchoring procedures for Acute Care Surgery pathway

Eight unique vetted membership-only closed Facebook groups were created for the MASTERS Program, including a group for bariatrics, hernia, colorectal, biliary, acute care, flexible endoscopy, robotics, and foregut. The Acute Care Surgery Facebook group is independent of the other groups and will be populated only by physicians, mostly surgeons or surgeons-in-training interested in Acute Care surgery.

The group provides an international platform for surgeons and healthcare providers interested in optimizing outcomes in a surgical specialty to collaborate, share, discuss, and post photos, videos, and anything related to a chosen specialty. By embracing social media as a collaborative forum, we can more effectively and transparently obtain immediate global feedback that potentially can improve patient outcomes, as well as the quality of care we provide, all while transforming the way a society’s members interact.

For the first two levels of the MASTERS Program, Competency and Proficiency, participants will be required to post videos of the anchoring procedures and will receive qualitative feedback from other participants. However, for the mastery level, participants will submit a video to be evaluated by an expert panel. A standardized video assessment tool, depending on the specific procedure, will be used. A benchmark will also be utilized to determine when the participant has achieved the mastery level for that procedure.

Once the participant has achieved mastery level, she/he will participate as a coach by providing feedback to participants in the first two levels. MASTERS Program participants will therefore need to learn the fundamental principles of surgical coaching. The key activities of coaching include goal setting, active listening, powerful inquiry, and constructive feedback [5, 6]. Importantly, peer coaching is much different than traditional education, where there is an expert and a learner. Peer coaching is a co-learning model where the coach is facilitating the development of the coached by using inquiry (i.e., open-ended questions) in a noncompetitive manner.

Surgicalcoaching skills are a crucial part of the MASTERS curriculum. At the 2017 SAGES Annual Meeting, a postgraduate course on coaching skills was developed and video recorded. The goal is to develop a coaching culture within the SAGES MASTERS Program, wherein both participants and coaches are committed to lifelong learning and development.

The need for a more structured approach to the education of practicing surgeons as accomplished by the SAGES MASTERS Program is well recognized [7]. Since performance feedback usually stops after training completion and current approaches to MOC are suboptimal, the need for peer coaching has recently received increased attention in surgery [5, 6]. SAGES has recognized this need and its MASTERS Program embraces social media for surgical education to help provide a free, mobile, and easy to use platform to surgeons globally. Access to the MASTERS Program groups enables surgeons at all levels to partake in the MASTERS Program curriculum and obtain feedback from peers, mentors, and experts. By creating surgeon-only private groups dedicated to this project, SAGES can now offer surgeons posting in these groups the ability to discuss preoperative, intraoperative, and postoperative issues with other SAGES colleagues and mentors. In addition, the platform permits transparent and responsive dialogue about technique, continuing the theme of deliberate, lifelong learning.

To accommodate the needs of this program, SAGES University is upgrading its web-based features. A new learning management system (LMS) will track progression and make access to SAGES University simple. Features of the new IT infrastructure will provide the ability to access a video or lecture on-demand in relation to content, level of difficulty, and author. Once enrolled in the MASTERS Program, the LMS will track lectures, educational products, MCE and other completed requirements. Participants will be able to see where they stand in relation to module completion and SAGES will alert learners to relevant content they may be interested in pursuing. Until such time that the new LMS is up and running, it is hoped that the SAGES Manual will help guide learners through the Masters Program Curriculum.

Conclusions

The SAGES MASTERS Program ACUTE CARE SURGERY PATHWAY facilitates deliberate, focused postgraduate teaching and learning. The MASTERS Program certifies completion of the curriculum but is NOT meant to certify competency, proficiency, or mastery of surgeons. The MASTERS Program embraces the concept of lifelong learning after fellowship and its curriculum is organized from basic principles to more complex content. The MASTERS Program is an innovative, voluntary curriculum that supports MOC and deliberate, lifelong learning.

References

1.

Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, Scott DJ. SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017;31(8):3061–71.Crossref

2.

Dreyfus SE. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177–81.Crossref

3.

Graham R, Mancher M, Miller Woman D, Greenfield S, Steinberg E. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011.

4.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6.Crossref

5.

Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32–4.Crossref

6.

Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282–3.Crossref

7.

Sachdeva AK. Acquiring skills in new procedures and technology: the challenge and the opportunity. Arch Surg. 2005;140:387–9.Crossref

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

D. Renton et al. (eds.)The SAGES Manual of Acute Care Surgeryhttps://doi.org/10.1007/978-3-030-21959-8_2

2. Appendicitis

Joshua J. Weis¹ and Elizabeth C. Hamilton¹  

(1)

Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

Elizabeth C. Hamilton

Email: [email protected]

Keywords

AppendicitisAppendectomyAcute appendicitisLaparoscopic appendectomy

Introduction

Appendectomy is the most common emergent abdominal operation performed. Over 300,000 appendectomies are performed each year in the United States alone. The lifetime risk of appendicitis is estimated to be about 9% for males and 7% for females [1]. In 2017, appendectomy is most commonly performed laparoscopically. When compared with open surgery, laparoscopic intervention is associated with fewer wound infections, earlier discharge from the hospital, and earlier return to normal activities [2]. Appendectomy is the gold standard for treatment of acute appendicitis. Modern management strategies, however, also include initial or definitive medical management with intravenous antibiotics, percutaneous drainage by interventional radiology, and possible interval appendectomy.

Indications

Assuming surgeon comfort and experience with laparoscopy, laparoscopic appendectomy should be considered in patients who either present with signs and symptoms of acute appendicitis or have radiologic evidence of inflammation in the region of the appendix. The most common presentation of acute appendicitis is a history of periumbilical pain migrating to the right lower quadrant, associated with nausea and/or anorexia. Physical exam findings classically include fever and right lower quadrant rebound tenderness. Laboratory findings of leukocytosis with a left shift support the diagnosis. Importantly, many patients do not have classic symptoms, and their complaints may be vague and include only right flank or pelvic pain, especially in cases of delayed presentation or a retrocecal appendix.

The differential diagnosis of acute appendicitis is broad and includes the following: regional adenitis, enteritis/ileitis, inflammatory bowel disease such as Crohn’s or ulcerative colitis, epiploic appendagitis, cecal or sigmoid diverticulitis, perforated ulcer disease, Meckel’s diverticulitis, pancreatitis, cholecystitis, incarcerated hernia, and urinary tract infection. Additional diagnoses in females include ectopic pregnancy, torsion of the ovary, hemorrhagic ovarian cyst, pelvic inflammatory disease, and pneumonia.

There is ongoing debate in the literature regarding the appropriate use of imaging in the diagnosis of acute appendicitis. CT scan is often performed in the emergency room before surgical consultation is obtained. A contrast-enhanced CT scan of the abdomen and pelvis showing a rim-enhancing appendix over 6 mm with surrounding inflammation in a patient with clinical concern for appendicitis is diagnostic. Ultrasound is an alternative imaging modality. However, the sensitivity and specificity of ultrasound vary significantly based on operator skill and the body habitus of the patient. Ultrasound is generally considered the preferred modality for children and pregnant patients [3]. MRI may be preferred in pregnant patients if ultrasound is indeterminate, but emergent MRI imaging is not available in all centers. Some data suggest that experienced clinicians can reliably diagnose appendicitis in young men without advanced imaging, and many clinicians feel comfortable omitting imaging in this population if signs and symptoms are classic [4, 5]. Ultimately, the choice of imaging depends on surgeon comfort level with the diagnosis and available resources at the institution.

Contraindications

Laparoscopic appendectomy will be safe for the vast majority of patients encountered. However, an open approach via a McBurney or Rocky-Davis incision may be preferred in patients with extensive adhesions from prior surgery or patients who will not tolerate insufflation due to medical co-morbidities. Patients with severe co-morbidities or those taking therapeutic anticoagulation may be appropriate candidates for a trial of medical management with IV antibiotics. Patients presenting in a delayed fashion with diffuse contamination may benefit from an open procedure to improve washout of the peritoneal cavity. Patients presenting with septic shock from perforation and abscess need rapid source control. Urgent image-guided drainage under local anesthesia may be helpful if this technique is available. However, sepsis should not be treated as a contraindication to immediate surgery via an open or laparoscopic approach, as long as these patients receive appropriate IV fluid resuscitation and intravenous antibiotics prior to general anesthesia.

Patient Preparation and Positioning

Open appendectomy technique has been described extensively elsewhere. Laparoscopic appendectomy should be considered for the initial surgical approach and is described here.

1.

All women of child-bearing age should have a pregnancy test.

2.

All patients should receive preoperative intravenous antibiotics to cover gram-negative and anaerobic organisms. Antibiotics are often started in the emergency room. Re-dosing antibiotics within 30 minutes prior to incision may be considered.

3.

Lower extremity sequential compression devices should be placed for DVT prophylaxis.

4.

The patient should be asked to urinate immediately before the operation. Alternatively, a Foley catheter should be placed to decompress the bladder. This will improve laparoscopic access to the pelvis and right lower quadrant and is particularly important if a suprapubic trocar is used.

5.

The patient should be padded and strapped appropriately to facilitate steep Trendelenburg and left-side-down positioning.

6.

If possible, tucking the patient’s left arm can assist the surgeon in their positioning at the shoulder of the patient, with the assistant on the same side to their left.

7.

As depicted in Fig. 2.1, video monitors may be placed at the foot of the bed, on the right side of the patient, or in both locations. The laparoscopic tower may be at the foot of the bed or lateral to the patient’s upper body on the right or left side of the patient. The surgeon and assistant stand on the left side of the patient.

Figure 2.1

Recommended room setup for laparoscopic appendectomy – the surgeon and assistant both stand on the patient’s left side. Left arm can be tucked. Monitors should be placed at the foot of the bed and to the patient’s right side. (Illustration by D. Henriquez)

Abdominal Entry and Trocar Placement

1.

An open or Veress needle technique may be used to gain entrance into the abdominal cavity using standard laparoscopic safety principles. Trocar placement is depicted in Fig. 2.2. The initial trocar is generally placed at the umbilicus. In these patients, the surgeon should be cognizant that the major vascular structures are only 2–3 cm away from the umbilicus with the patient in the supine position. The trocar can be 5 mm or 12 mm depending on the preferred location for introducing a stapler. Palmer’s point (left upper quadrant subcostal) should be considered as an alternative entry point in patients with suspected dense adhesions from previous surgery.

2.

Most surgeons use three trocars to triangulate on the right lower quadrant. The size and the position of the trocars vary based on surgeon preference, but the following principles should be kept in mind. 5 mm trocars are adequate for most energy devices, dissecting instruments, and a 5 mm camera. However, to remove the appendix, at least one 11 mm trocar will be needed to accommodate a specimen retrieval bag. Also, most laparoscopic staplers require a 12 mm trocar. As such, one 12 mm trocar and two 5 mm trocars are typically used.

3.

Initial gross evaluation of the abdomen using diagnostic laparoscopy may be helpful to identify unexpected findings and alter trocar placement at that time if needed. We prefer a 5 mm angled laparoscope, since it works well through any trocar and can be moved to any other site later when a stapler or specimen retrieval bag is introduced.

4.

The patient should be positioned in the Trendelenburg position and rotated toward the left.

5.

Two additional trocars should be placed under direct visualization, commonly in the left lower quadrant and in the suprapubic position cephalad to the level of the bladder. The trocars can be two 5 mm trocars if the periumbilical port was a Hasson (12 mm), or a 5 mm and an 11/12 mm trocar depending on the method the surgeon plans to use for stump closure (Fig. 2.2).

6.

Alternative trocar placement options are also shown.

Figure 2.2

Possible trocar placements for laparoscopic appendectomy – standard placement is umbilical, suprapubic, and left lower quadrant. Alternative/optional port can be placed in the right lower quadrant for an assistant to retract. (Illustration by D. Henriquez)

Operative Steps

1.

After examining the abdomen for other pathologies, the initial step in the operation is to identify the appendix (Fig. 2.3). This is sometimes very easy but is often more difficult than it sounds. Adherence to basic principles minimizes potential difficulties. Positioning the bed in steep Trendelenburg position with the right side elevated as well can facilitate removing surrounding structures from the right lower quadrant. First, the omentum and the small bowel should be swept cephalad to expose the right lower quadrant. Next, the cecum and the terminal ileum should be identified. The appendix is always found where the taenia meet at the base of the cecum lateral to the ileocecal valve (Fig. 2.3). If the cecum can be seen clearly, but the appendix cannot, a retrocecal appendix should be suspected. In this case, the cecum must be mobilized off of the retroperitoneum by taking down the White Line of Toldt and rolling the cecum medially to expose the posterior cecal wall and appendix.

2.

Once the appendix is identified, care must be taken to avoid grasping it in such a way that the appendix ruptures. Atraumatic instruments such as a Babcock or Spring graspers may be helpful. If perforation occurs, it should be contained in the area and aspirated out completely before irrigation is used. Alternatively, the mesoappendix may be grasped to provide traction without directly grabbing the inflamed appendix.

3.

Adhesions between the appendix and surrounding structures such as the terminal ileum, the omentum, the ligament of Treves, and the peritoneum should be taken down with care. Adhesions can often be taken down bluntly with graspers or a Kittner. In some cases, energy devices such as hook monopolar energy, an ultrasonic dissector like the Harmonic scalpel, or an advanced bipolar device like the Ligasure are most efficient and most hemostatic.

4.

Dissection must be continued until the entire appendix is visualized entering the wider cecal wall, taking care to ligate the appendix flush with the cecum (Fig. 2.4) and not to leave an unrecognized appendiceal stump that could lead to later presentation with stump appendicitis.

5.

Once the base of the appendix is clearly exposed where it enters the cecum, a decision must be made on how to divide both the base of the appendix and the mesoappendix containing the appendiceal artery. A laparoscopic stapling device or an Endoloop may be used to ligate the appendix. A hemaclip, a vascular stapling device, or an energy source may be used to ligate and divide the appendiceal artery within the mesoappendix. A window can be created between the appendix and the mesoappendix bluntly with Maryland forceps, taking special care not to poke the tips of the dissecting instrument into the base of the cecum.

6.

If a stapler is to be used, the base of the appendix and the mesoappendix are each controlled with a separate staple firing (Fig. 2.4). Taking each structure separately allows the use of different staple heights, ensures good apposition of staples, and may minimize bleeding and stump leaks. Before firing the stapler, verification of the positions of the cecum and terminal ileum is necessary to ensure that neither structure is inadvertently grasped by the stapler. A blue load of a linear laparoscopic stapler (open staple height 3.5 mm) is used to ligate and divide the base of the appendix, and a white load (open staple height 2.5 mm) is used for the mesoappendix. The structures can be divided in either order.

7.

If the choice is made not to use a stapler, the mesoappendix may be dissected off the appendix from tip to base using an energy device (ultrasonic or bipolar vessel sealer) that both obtains