TAG: "Surgery"

Peer feedback through social media helps resident improve surgery skills

The process gives surgeons an ‘egoless’ opportunity to refine techniques.

Jim Hu, UCLA

Surgical residents who received anonymous feedback from their peers through a social networking site showed greater improvement in their robotic surgery skills than those who received no such feedback, a UCLA study shows.

The study, published in the early online edition of Annals of Surgery, is the first to examine the use of social networking to facilitate peer review of surgical procedure videos, said senior author Dr. Jim Hu, the Henry E. Singleton Professor of Urology and director of robotic and minimally invasive surgery in the urology department at the David Geffen School of Medicine at UCLA.

Research participants included 41 urology and gynecology residents from UCLA and the University of Michigan who used a robotic surgery simulator to sew and tie two tubes together. The residents were randomized into one of two groups — an intervention group in which the residents videotaped their efforts and posted the videos on a Google Plus group forum for anonymous review and comment by their peers in the same group, and a control group in which participants did not videotape or post their work for review.

The residents performed the same simulated robotic procedure three times. The study found that residents in the intervention group improved their technique in subsequent attempts, had shorter completion times and earned better scores from the simulator for technical efficiency, accuracy and economy of motion.

“We have demonstrated that social networking can be a viable forum for coaching, both for residents honing their craft and for practicing surgeons,” Hu said. “Technique matters, regardless of what type of surgery you’re doing. Surgeons who invest time in reviewing their techniques on video and seek the feedback and coaching of others ultimately will do better in terms of performance.”

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Joint Commission certifies UC Irvine hip, knee replacement programs

Gold Seal of Approval denotes commitment to highest quality patient care.

UC Irvine Health has earned The Joint Commission’s Gold Seal of Approval for its hip and knee joint replacement programs by demonstrating compliance with the organization’s national standards for health care quality and safety in disease-specific care.

UC Irvine Health underwent a rigorous on-site review in May. A Joint Commission expert evaluated the programs for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management.

The commitment to these standards is reflected in the UC Irvine Health Joint Replacement Surgical Home. Developed at UC Irvine Medical Center, this model coordinates the roles of orthopaedic surgeons, anesthesiologists and nursing staff before, during and after surgery to ensure that patients receive the most efficient and comprehensive care available. The surgical home model has measurable standards for perioperative care and ensures that potential improvements are identified and incorporated into the program.

“The ability to achieve such high level of care and patient satisfaction is only possible due to the dedication and hard work put in daily by our joint replacement surgical home team,” said Ran Schwarzkopf, M.D., assistant clinical professor, UC Irvine Health Department of Orthopaedic Surgery and head of the hip and knee surgery service. “It is this team work that allows us to be a center of excellence in total hip and knee replacement surgery.”

The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate clinical programs across the continuum of care. Certification requirements address three core areas: compliance with consensus-based national standards; effective use of evidence-based clinical practice guidelines to manage and optimize care; and an organized approach to performance measurement and improvement activities.

“In achieving Joint Commission certification, UC Irvine Health has demonstrated its commitment to the highest level of care for its patients undergoing knee or hip joint replacement,” says Jean Range, M.S., R.N., C.P.H.Q. executive director, Disease-Specific Care Certification, The Joint Commission. “Certification is a voluntary process and I commend UC Irvine Health for successfully undertaking this challenge to elevate its standard of care and instill confidence in the community it serves.”

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UCLA physicians use Google Glass to teach surgery abroad

Teaching surgeons can watch operation and comment via this tech tool.

Imagine watching a procedure performed live through the eyes of the surgeon. That’s exactly what surgical leaders in the United States were able to do while overseeing surgeons training in Paraguay and Brazil with the help of UCLA doctors and Google Glass.

UCLA surgeon Dr. David Chen and surgical resident Dr. Justin Wagner have made it their mission to teach hernia surgery around the world and are harnessing the latest technologies to help.

“Hernia repair is the most common operation performed worldwide,” said Chen, assistant clinical professor of general surgery at the David Geffen School of Medicine at UCLA. “From a global health perspective, it is as cost-effective as immunizations because it allows patients to regain function and resume work and other daily activities.”

It is also an easily teachable procedure that lends itself to the advent of this kind of technology, according to Chen, associate director of surgical education and clinical director of the Lichtenstein Amid Hernia Clinic at UCLA.

The team used Google Glass, which is worn like conventional glasses, but houses a tiny computer the size of a Scrabble tile outfitted with a touch-pad display screen and high-definition camera that can connect wirelessly to stream live.

With Chen and Wagner’s help, local surgeons at a hospital in Paraguay in late May wore Google Glass while performing adult surgeries to repair a common type of hernia in which an organ or fatty tissue protrudes through a weak area of the abdominal wall in the groin. This type of hernia is commonly found in both children and adults.

Through Google Glass, the surgeries were viewed “live” via wireless streaming in the United States to a select group of leading surgeons who could watch and oversee the procedures. The experts could also transmit their comments to the surgeon, who could read them on the Google Glass monitor. The surgeries are also being archived for later training purposes as well. Chen added that the educational program ensures competency and quality of the operations.

“We are one of the first to use Google Glass in teaching and training surgeons from outside a country,” said Chen. And he says hernia surgery is just the beginning.

“Our goal is to utilize the latest technologies like Google Glass, Facebook and Twitter in connecting everyone in medicine worldwide for educational purposes that can help improve medical care in resource-poor countries,” said Chen. “These cost-effective applications can ultimately be used for other surgical procedures and medical training as well.”

The UCLA team also visited Brazil, where they used Google Glass during three hernia surgeries and also streamed a live debriefing session afterwards. The team plans to train 15 surgeons from around the country in September. These surgeons will then become trainers to teach other surgeons at several regional hospitals for underserved patients. Similar programs will be implemented in Haiti, the Dominican Republic, Guatemala and Ecuador this fall.

These training projects are part of an educational arm of Hernia Repair for the Underserved, a nonprofit organization dedicated to providing free hernia surgery to children and adults in the Western Hemisphere. Chen, who serves on the organization’s board, is spearheading these educational projects with the UCLA team to help “train the trainers” and increase the number of surgeons performing this procedure in underprivileged countries in the Western Hemisphere.

Chen and Wagner also work closely with UCLA’s Center for Advanced Surgical and Interventional Technology (CASIT) in developing new ways to help educate doctors remotely.

They have even streamed surgical lectures to Haiti from UCLA Medical Center, Santa Monica.

“We are developing practical applications for these technologies so that surgeons in any setting can have access to the global surgical community from within their own operating rooms,” said Wagner. “Even after the training is over, local surgeons can be teleproctored remotely so they will remain connected to experts worldwide.”

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Study supports use of bone-stabilizing devices for sternal repairs

Standard approach to repairing sternum fractures has been wire ‘stitches.’

Michael Wong, UC DavisDevices made of metal plates and screws that can precisely align and stabilize fractured bones as they heal can safely and effectively repair the sternum, according to a review of UC Davis surgeries published in the May issue of the Annals of Plastic Surgery.

Over the past five decades, the standard approach to repairing sternum fractures has been wire “stitches,” according to Michael Wong, professor of surgery at UC Davis and senior author of the journal paper.

“Chest surgeons have been reluctant to make the transition from wire closure to rigid sternal fixation, even though it has become the standard-of-care for other bone reconstructions,” said Wong, a specialist in plastic and reconstructive surgery. “Our study adds to growing evidence that it can be beneficial for the breastbone, too.”

To get a cumulative view of their experiences with rigid sternal fixation, Wong and his colleagues evaluated risk factors and outcomes for 57 patients at UC Davis Medical Center between 2006 and 2012. The patients included males and females between the ages of 16 and 70 who needed breastbone reconstruction or stabilization for a variety of reasons.

Thirty-five patients had sternotomies, or surgical divisions of the breastbone, during open chest surgery. All of them were at high risk for developing mediastinitis — a potentially fatal inflammation of the space around the heart — because of obesity, diabetes, COPD or other medical factors. An additional 14 had prior sternal reconstructions that failed, four had sternums damaged due to trauma and four had congenital abnormalities of the sternum.

The outcomes showed that none of the patients developed mediastinitis, which may occur in up to 15 percent of high-risk patients following chest surgery that uses the breastbone for access to the heart. Fourteen patients had mostly minor post-operative complications. Only three of them (fewer than 1 percent) had complications that warranted reoperations to remove or adjust the sternal plating hardware.

“All surgical techniques can have complications, but a growing portion of our work is treating complications of wire closures with sternal plates and screws,” said Wong. “It’s time to start considering rigid techniques first when it comes to repairing the sternum, at the very least among patients at higher risk for complications.”

This study is one of a series from Wong on rigid fixation. In 2012, he showed that the sternal devices resulted in shorter healing times and reduced pain when compared to wire closures, and he will soon publish a cost comparison of both approaches. He is also working with UC Davis cardiothoracic surgeon Broadus Zane Atkins on studies to determine which type of rigid device works best for patients with osteoporosis, a notoriously challenging condition for surgeons given that it can make patients’ bones more brittle and difficult to repair.

The current study — titled “Rigid Fixation for the Prevention and Treatment of Sternal Complications: A Review of Our Experience” — had no external funding. Wong’s co-authors were UC Davis plastic surgery residents Rahim Nazerali and Katharine Hinchcliff.

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UCSF urologist wins coveted Barringer Medal

Peter Carroll honored for his work.

Peter Carroll, UC San Francisco

The American Association of Genitourinary Surgeons awarded its 2014 Barringer Medal to Peter R. Carroll, M.D., M.P.H., chair of the UCSF Department of Urology, during the April annual meeting. This award recognizes a younger member of the organization who is achieving “distinguished accomplishments” and is meant to encourage and stimulate his or her continued work.

Marshall Stoller, M.D., professor and vice chair of the UCSF Department of Urology, presented the Barringer Medal to Carroll.

“Peter’s tireless effort in promoting active surveillance as a viable and safe option of treatment for men with low-risk prostate cancer is commendable,” Stoller said.

Created in 1954, the award honors Benjamin S. Barringer, the first chief of urology at Memorial Hospital in New York City. Barringer was an early innovator of brachytherapy in 1915 where he placed radium needles for treatment of prostate cancer. UCSF urologist Frank Hinman Jr., M.D., is the first and only other UCSF faculty member to have won the Barringer Medal, when he was honored in 1984.

Carroll is currently co-investigator or principal investigator on numerous research studies including a grant of almost $10 million from the Department of Defense called the “Transformative Impact Award.” Carroll’s past awards include the 2010 Eugene Fuller Triennial Prostate Award from the American Urological Assocation (AUA), and the SUO Medal from the Society of Urologic Oncology (SUO). He is also the Ken and Donna Derr Chevron Distinguished Professor in the Department of Urology; and associate dean and director of clinical services and strategic planning in the UCSF Helen Diller Family Comprehensive Cancer Center.

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MRI-guided biopsy for brain cancer improves diagnosis

Approach — a California first — increases accuracy of diagnosis.

Neurosurgeons at UC San Diego Heath System have, for the first time, combined real-time magnetic resonance imaging (MRI) technology with novel non-invasive cellular mapping techniques to develop a new biopsy approach that increases the accuracy of diagnosis for patients with brain cancer.

“There are many different types of brain cancer. Making an accurate diagnosis is paramount because the diagnosis dictates the subsequent course of treatment,” said Clark C. Chen, M.D., Ph.D., vice chairman of research, division of neurosurgery, UC San Diego School of Medicine. “For instance, the treatment of glioblastoma is fundamentally different than the treatment for oligodendroglioma, another type of brain tumor.”

Chen said that as many as one third of brain tumor biopsies performed in the traditional manner can result in misdiagnosis. He cited two challenges with conventional biopsy.

“First, because distinct areas of brain tumors exhibit different cell densities and higher cell densities are generally associated with higher tumor grade, biopsies taken from one region may yield a different diagnosis than if another area is biopsied,” said Chen. “Second, because tumors are hidden within the brain, surgeons must use mathematical algorithms to target where the biopsy should occur. As with all calculations, the process is subject to errors that the surgeon cannot easily correct in real time once the biopsy has begun.”

Chen’s team applied an MRI technique called Restriction Spectrum Imaging (RSI) to visualize the parts of the brain tumor that contain different cell densities.

“RSI allows us to identify the regions of the cell that are most representative of the entire tumor,” said Chen. “By targeting biopsies to these areas, we minimize the number of biopsies needed but still achieve a sampling that best characterizes the entire tumor.”

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Children with Down syndrome have better heart surgery outcomes

Mortality rates for congenital heart disease repairs are lower in kids with Down syndrome.

Jacqueline Evans, UC Davis

Researchers at UC Davis Children’s Hospital have shown that children with Down syndrome have significantly better in-hospital survival rates after surgeries for congenital heart disease (CHD) than their genetically typical peers.

While post-surgical mortality rates for children with Down syndrome have been studied before, this is by far the most comprehensive effort to date. Using the Kids’ Inpatient Database (KID), the researchers looked at results from almost 80 different procedures, performed on more than 50,000 children across the United States during 2000, 2003, 2006 and 2009.

The overall in-hospital mortality rate for children with Down children was 1.9 percent as compared with 4.3 percent for children without Down syndrome. The paper was published in the journal Circulation: Cardiovascular Quality and Outcomes.

“We’ve known for some time that children with Down syndrome do better after certain procedures,” said lead author Jacqueline Evans, assistant professor at UC Davis Children’s Hospital. “But even when you correct for surgical risk, prematurity, the presence of a major non-cardiac structural abnormality and age at the time of surgery, children with Down syndrome have lower in-hospital mortality rates across a wide spectrum of repairs.”

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MRI-guided laser treatment for brain cancer a first in state

Technology helps treat malignant tumor deep inside a patient’s brain.

Neurosurgeon Clark Chen treats recurrent brain cancer with MRI-guided laser technology at UC San Diego Health System.

Using a novel magnetic resonance imaging (MRI)-guided laser technology, neurosurgeons at UC San Diego Health System have successfully treated a malignant tumor deep inside a patient’s brain. This is the first time that this FDA-approved laser-based treatment has been performed in California.

“The patient’s brain tumor was located in the thalamus. Normally, to access a tumor in this region, the surgeon would have to remove considerable healthy brain tissue, thus subjecting the patient to significant neurologic injury,” said neurosurgeon Clark C. Chen, M.D., Ph.D., vice chairman of research, UC San Diego Division of Neurosurgery.  “This MRI-guided laser technology helps neurosurgeons preserve healthy brain tissues while allowing treatment of tumors that would otherwise be inoperable.”

Chen and his team used a technique called laser interstitial thermal therapy. The procedure is performed inside an MRI machine while the patient is under general anesthesia.  A dime-size hole is created in the patient’s skull to access the tumor. A laser probe is then inserted into the tumor under real-time MRI monitoring and computer guidance. When the tumor is reached, the laser beam is activated, heating and destroying tumor cells.

“It is well-known that MRI can be used to generate detailed images of the brain. What is less known is that MRI can also be used to measure the internal temperature of the brain,” said Chen. “With this application, I can view the tumor in real time as it is being destroyed while customizing the effects of the laser to the tumor without injuries to the surrounding normal brain. This incredible visualization allows neurosurgeons to preserve billions of neuronal connections that are essential for normal brain function.”

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The future of ophthalmology

New UC Davis facility advances the skills of eye surgeons.

Medical students and residents in the new ophthalmology training lab are able refine their surgical skills for procedures that require the use of high-powered microscopes.

The UC Davis Eye Center has opened a new state-of-the-art facility for teaching microsurgery techniques to the next generation of surgeons. Called the Lanie Albrecht Foundation Microsurgical Training Laboratory, the facility allows medical students and residents in ophthalmology and other specialties – including neurosurgery, orthopaedics, plastic surgery and veterinary medicine – to finesse their skills at performing surgeries that require the use of high-powered microscopes.

“This lab is all about enhancing the quality of patient care,” said Thomas Nesbitt, associate vice chancellor for strategic technologies and alliances at UC Davis.

“By establishing this technology-enabled learning environment, our medical residents can further refine their skills before entering the operating room.”

Funded entirely through a generous gift from the Lanie Albrecht Foundation, the new facility has seven fully equipped learning stations that ophthalmology residents can use to practice procedures such as corneal and retinal surgeries, cataract surgery and restorative oculoplastic surgery using grapes or animal eyes. Their work can be projected onto a high-resolution screen so faculty physicians can guide the process. Training sessions also can be recorded for analysis or to track milestones in each trainee’s progress.

“Practice in a controlled environment is a crucial part of becoming a skilled surgeon, and the new lab makes that possible,” said ophthalmology resident Natasha Kye.

“Residents have always gained high quality surgical training at UC Davis,” added Mark Mannis, chair of the Department of Ophthalmology. “But this wonderful new facility enables us to nurture the next generation of surgeons at a whole new level.”

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Improving knee replacements

UC San Diego first in nation to use device that boosts surgical precision and accuracy.

Francis Gonzales, UC San Diego

Each year, approximately 600,000 total knee replacement procedures are performed in the United States, a number that is expected to rise exponentially in the next decade as the population ages. Successful surgeries require precise alignment in the knee, a challenging task made even more daunting by the expected rise in procedures. To help meet this demand, UC San Diego Health System is the first in the nation to use iASSIST, a computer navigation system with Bluetooth-like technology that improves surgical precision and accuracy in total knee replacements, decreasing the need for revision surgery.

The FDA-approved iASSIST device, designed by Zimmer Holdings Inc., allows the surgeon to verify each surgical step, such as bone cuts and overall alignment, in real time, reducing mechanical errors during total knee replacements. The device is made up of small electronic pods, which are essentially mini-computers with wireless technology similar to smartphones. These electronic pods snap onto conventional instruments used in knee replacement surgery. By simply moving the knee in different positions during surgery, the device registers the anatomic axis of the leg unique to that patient, which guides each bone cut and ultimately places the knee implant in a more accurate alignment.

“This innovative technology allows us to deliver a more personalized knee to the patient and provide extreme accuracy in implant placement. Studies have shown that total knee replacement surgery has a higher failure rate when the knee is mal-aligned. This device enables orthopedic surgeons to restore a patient’s normal alignment with precision in a reproducible fashion, decreasing revision surgery and providing a more natural feel of the implant for the patient,” said Francis Gonzales, M.D., with the Department of Orthopedic Surgery.

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Lifesaving surgery makes for an extra special Valentine’s Day

Minimally invasive heart procedure followed by lung transplant.

All smiles, Mike Boyle and his wife, Ellen, are looking forward to celebrating a special Valentine's Day.

Mike Boyle has good reason to give his wife and family extra hugs on Valentine’s Day.

Just two months ago, he was slowly suffocating from pulmonary fibrosis, a condition with no cure that causes scar tissue build-up in the lungs, making it difficult to breathe. In addition, his main heart valve was so clogged with calcium deposits that it couldn’t open wide enough to adequately pump blood through his body.

Feeling exhausted, the Thousand Oaks resident had curtailed all his activities and needed to carry around an oxygen tank to help him breathe.

Given his declining heart condition, it was too risky for him to receive a much needed lung transplant, a factor that the UCLA lung transplant committee took into consideration before turning him down. Given that UCLA handles the most advanced, serious patient cases and he still didn’t qualify, it looked like Boyle had truly run out of options.

But fortunately, there was one left. The heart team at UCLA was offering a new procedure that is designed for patients who are too sick to have the conventional surgery needed to replace the main heart valve. Luckily, Boyle qualified.

The minimally invasive procedure, called Transcatheter Aortic Valve Replacement (TAVR), involves far fewer surgical risks. TAVR allows doctors for the first time to replace the aortic valve without open heart surgery. It’s an attractive alternative for patients like Boyle, who aren’t candidates for traditional surgery.

The usual TAVR approach is to deliver the valve to the heart via an artery in the groin using a catheter, which is a hollow delivery tube. But in Boyle’s case, these arteries had blockages that made this approach impossible. Alternatively, a small incision is made on the side of the chest, and the valve is delivered through the lowest part of the heart called the apex. Once in place, the valve is opened, and it starts working immediately.

Boyle had the TAVR procedure using this alternative approach last June with a heart team led by Dr. Richard Shemin, chief of cardiothoracic surgery, and Dr. William Suh, assistant clinical professor of medicine and interventional cardiology, both with UCLA’s David Geffen School of Medicine and UCLA Health System.

Boyle’s heart was doing so well after the valve replacement that he was encouraged to try to get listed again for a lung transplant. This time he was approved by the UCLA committee and received his lifesaving lung transplant in late November with a team led by Dr. Abbas Ardehali, a professor of cardiothoracic surgery and director of the heart and lung transplantation program at UCLA.

Today, Boyle is progressing nicely, say his doctors — and he couldn’t be happier.

“I don’t feel as physically limited as before and have a new lease on life,” said Boyle, who doesn’t need to carry oxygen anymore and has started to exercise as well.

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UCLA awarded $6M to study ways to restore hand movement after paralysis

Promising therapy uses electrical impulses to stimulate dormant pathways within spinal cord.

Daniel Lu, UCLA

The National Institute of Biomedical Imaging and Bioengineering has awarded UCLA researchers Dr. Daniel Lu (Brentwood) and Dr. Reggie Edgerton (Bel Air) a $6 million, five-year grant to explore new therapies for the approximately 273,000 Americans living with spinal-cord injuries. Some 12,000 Americans suffer such injuries each year.

The UCLA research will focus on restoring hand function to patients paralyzed from the neck down. Cervical spinal-cord injuries — those involving the neck — make up more than half of the cases in the U.S.

“Spinal-cord injury typically strikes people in the prime of their lives, with nearly half between ages 16 and 30,” said Lu, an assistant professor of neurosurgery at the David Geffen School of Medicine at UCLA and a clinician at the UCLA Spine Center. “Currently there are no effective treatments for spinal-cord injury, and the resulting paralysis has been viewed as permanent. We are exploring ways to change that.”

In seeking to help people with cervical spinal-cord injuries regain the use of their hands, the UCLA team is looking to build on findings from Edgerton’s earlier work, conducted with Russian scientist Yury Gerasimenko, on lumbar spinal-cord injuries — those to the lower spine.

V. Reggie Edgerton, UCLA

“Recovering the ability to use one’s hands is a top priority for people with cervical spinal-cord injury,” said Lu, who grew up in Palos Verdes. “We aim to restore patients’ independence by returning their ability to type on a keyboard, open doors and transfer themselves between their bed and wheelchair.”

The most promising therapy uses electrical impulses to stimulate dormant pathways within the spinal cord, allowing the brain’s previously unrecognized signals to reach past the injured area.

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