Surgery Commons^™

Rigid Sternal Fixation Alone Does Not Result In A Reduction In Postoperative Opiod Administration Following Cardiac Surgery, Jane Branch, Chinedu Okoli, Kyla Wigant, Jaime Rabb, Robert S. Kramer, Anne Hicks, Ansar Hassan

Costas T. Lambrew Research Retreat 2025

Background: Persistent postoperative pain, infection, and sternal dehiscence are devastating complications after cardiac surgery that affect patient quality of life and increase healthcare system burden. Chronic sternal pain lasting more than 1 year affects 25 to 33% of cardiac surgery patients, and wound complications such as infection and sternal nonunion represent significant peri-operative risk factors1,2. Wire cerclage (WC) is the most widely accepted sternal closure technique among cardiac surgeons because of its perceived lower rates of sternal dehiscence, wound infection, and cost.

Creating Capacity To Accommodate Additional Cardiac Catheterization Procedures, Kristin Anthony

Operations Transformation

Patient access to diagnostic outpatient (OP) cardiac catheterization is limited by a perceived lack of capacity. Outpatient cardiac cath pts flow through the ACU for pre/post procedure care. Current schedule limits pts that may be scheduled through the ACU to two OP procedures/day. Cardiologists request the ability to schedule beyond the two procedures/day allowed. Significant variation in pre/postoperative care orders exist amongst cardiologists resulting in variability in length of stay. Cardiac procedures are booked either as 60/90/120 minutes – Epic case averaging technology is not active in the cath lab. As a result, the case minutes in the cath lab …

Risky Business: Creating A Process To Review Accuracy Of American Society Of Anesthesia (Asa) Classification And To Improve Overall Quality Risk Adjustment Of Surgical Patients, Jane Kinney, Sonja Orff, Robyn Begin, Nicholas Flavin, Eira Hyrkas, Christopher Adams, Ian Neilson

Costas T. Lambrew Research Retreat 2024

Through interdisciplinary education and the creation of an audit process, we have observed a 30.6% reduction in the number of ASA assignment misclassifications.

Variations Exist In Hospital And Patient-Reported Outcomes Following Total Hip Arthroplasty According To Biological Sex, Catherine Call, Andrew Lachance, Thomas Zink, Henry Stoddard, Callahan Sturgeon, George Babikian, Adam Rana, Brian J. Mcgrory

Costas T. Lambrew Research Retreat 2024

Introduction

• The effect of biological sex on the outcomes of THA remains unclear.

• Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes.

Healthcare Enabled By Artificial Intelligence In Real-Time, Felistas Mazhude, Robert S. Kramer, Qingchu Jin, Paul Terwilliger, Alan Hicks, Tyler Kelting, Douglas Sawyer, Jaime Rabb

Costas T. Lambrew Research Retreat 2024

INTRODUCTION: The HEART (Healthcare Enabled by Artificial Intelligence in Real-Time) Project pioneers developing real-time machine learning (ML) predictive analytics to address the need to improve outcomes during recovery from open heart surgery. Our broad objective is to enhance patient outcomes by developing, validating and deploying predictive algorithms into the hands of clinical teams as an early warning and guidance system, allowing care teams an opportunity to be proactive.

The Association Of Season Of Surgery And Patient Reported Outcomes Following Total Hip Arthroplasty, Catherine M. Call, Andrew Lachance, Zachary Radford, Henry Stoddard, Callahan Sturgeon, George Babikian, Adam Rana, Brian J. Mcgrory

Costas T. Lambrew Research Retreat 2024

Introduction

• Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA).

• Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience.

• The aim of this study was to investigate if there were differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season in an area with 4 distinct seasons.

Robotic Vs. Laparoscopic Bariatric Surgery, Chloe Aiken, Abigail Reera

Nurse Residency

Background: As OR nurses, we have seen an increase in the number of robot-assisted bariatric surgeries instead of being performed laparoscopically. In the United States, the first surgical robotic telepresence system became available in 1987. From there, IntuitiveSurgical, Inc. reworked that system to create numerous prototypes leading to the DaVinci series that we utilize at SMHC.

Shortening The Postoperative Length Of Stay Following Total Knee Arthroplasty Does Not Negatively Impact Short-Term Patient Outcomes; A Retrospective Review Of The Response To The Covid-19 Pandemic, Bailey Shevenell, Johanna Mackenzie, Cassandra Lieblein, Brian J. Mcgrory, Michael Becker, Nicholas Colacchio, Adam Rana

Costas T. Lambrew Research Retreat 2023

Safely Decreasing Postoperative Length of Stay for Total Knee Arthroplasty (TKA) Patients Following the COVID-19 Pandemic

Conversion Total Hip Arthroplasty: Perioperative And Postoperative Outcomes With The Able Approach, Bailey Shevenell, Johanna Mackenzie, Sarah Hearns, George Babikian, Brian J. Mcgrory, Adam Rana

Costas T. Lambrew Research Retreat 2023

The ABLE™ Approach for Conversion Total Hip Arthroplasty decreases surgical duration and length of stay

The Use Of The Ipack Block With The Adductor Canal Block (Acb) Decreases 48-Hour Narcotic Usage And Postoperative Pain Following Total Knee Arthroplasty, Bailey Shevenell, Johanna Mackenzie, Matthew Hersch, Michael Becker, Brian J. Mcgrory, Nicholas Colacchio, Adam Rana, Ryan Mountjoy, Rob Hubbs

Costas T. Lambrew Research Retreat 2023

Adductor Canal and iPACK Blocks reduce pain levels and narcotic consumption following Total Knee Arthroplasty

Pre-Operative Anxiety Related To Major Urogynecologicsurgery, Nadi Nina Kaonga, Mary C Brandes, Caroline Foust-Wright

Costas T. Lambrew Research Retreat 2022

Introduction •Higher levels of pre-operative anxiety are associated with adverse outcomes1-3(e.g., delayed recovery, higher post-op pain levels) •Most evidence arose from cardiothoracic and orthopedic literature (on emergent surgeries) and there is opportunity to further understand perioperative anxiety and elective/quality of life surgeries [within gynecology]4

Perioperative And Postoperative Outcomes Of Morbidly Obese Patients Undergoing Primary Elective Total Hip Arthroplasty With A Muscle Sparing Approach, Brian J. Mcgrory, George Babikian, Adam Rana

Costas T. Lambrew Research Retreat 2022

Obesity is associated with an increased risk of complications after total hip arthroplasty (THA), including infection and dislocation. •Due to the higher risk of osteoarthritis in obese individuals, understanding factors that can reduce the risk of complications is important. •This study examined the outcomes of morbidly obese (BMI ≥ 40) compared to healthy weight patients(BMI between 18.5-24.9 kg/m2)who underwent a THA with the ABLEapproach. •The ABLE approach: •This approach uses the interval between the anterior aspect of the gluteus mediusand the posterior aspect of the tensor fascia lata. •ABLE is minimally invasive, muscle sparing, and is associated with less painful …

“Cystectomy…What Bugs You?” Creation Of An Institutional Antibiogram, Erin Santos

Costas T. Lambrew Research Retreat 2022

BACKGROUND: Radical cystectomy is associated with high rates of post operative morbidity and mortality to improve readmission rates following radical cystectomy, a post cystectomy discharge pathway was created. We set out to create an institution specific antibiogram to identify and target most common causative organisms to specifically decrease genitourinary infection related complications.

A Rare Entity: Case Report Of Recurrent Hypertrophic Pyloric Stenosis, Astrid A. Gleaton, Kartikey Pandya

Journal of Maine Medical Center

Introduction: Hypertrophic pyloric stenosis (HPS) is well known in pediatric surgery and has good outcomes after pyloromyotomy.1 Emesis in the immediate postoperative period occurs in 40% of patients with HPS and is attributed to gastroparesis from prolonged gastric distention.2 Emesis presenting weeks to months after pyloromyotomy prompts an evaluation that often yields pathology unrelated to HPS. Because recurrent HPS is rare, making this diagnosis highlighted the importance of practicing broad differential diagnoses, ruling out most common causes, and including obscure etiologies.

Clinical Findings: A 3-week-old male born after full-term gestation with a history of HPS underwent an uncomplicated laparoscopic pyloromyotomy. …

Implementing A Clinical Practice Guideline For Pediatric Appendicitis Safely Reduced Health Care Use And Improved Antimicrobial Stewardship, Jack Vernamonti, Robin Cotter, Jennifer Jubulis, Kartikey Pandya

Journal of Maine Medical Center

Introduction: Appendicitis is the most common emergency surgical disease in children. Those with perforated appendicitis have a more complicated and varied course. Through a clinical practice guideline (CPG), we sought to reduce computed tomography scans, laboratory draws, and exposure to broad-spectrum antibiotics without adversely affecting length of stay, hospital readmission, or repeat antibiotic administration.

Methods: Electronic records were retrospectively reviewed before and after CPG implementation, and data was collected in REDCap.

Results were reported as mean or percent incidence, and statistical analysis was done using a Student’s t-test, Mann-Whitney U test, or Pearson’s χ2 with P < .05 considered significant. Results: One hundred patients with a perforated appendix (50 before and 50 after CPG implementation) were included in our analysis. Length of stay (4.98 vs 4.46 days; P = .25), hospital readmission rate (10% vs 14%; P = .54), and additional antibiotic administration (2% vs 4%; P = .56) did not change. We observed no difference in the Pediatric Appendicitis Score (9 vs 9; P = .48) and a trending increase in evaluation at an outside hospital (56% vs 74%; P = .06). Rates of computed tomography scans did not differ overall (50% vs 40%; P = .31), but showed a decreasing trend at our institution (30% vs 12%; P = .06). We also found fewer post-operative laboratory studies (90% vs 38%; P < .01) and patients who received broad-spectrum intravenous antibiotics (92% vs 18%; P < .01).

Discussion: Through implementing the …

Perceptions Of Self-Efficacy And Experiences Of Mindfulness On Pain And Anxiety In Patients Undergoing A Colorectal Surgery: A Prospective Mixed Methods Study, Rebecca Brown, Julie Fitzgibbons, Rachel Farrington

Costas T. Lambrew Research Retreat 2021

Introduction

• Pain and anxiety have a physiological response on the body.

• Increased heart rate, respiratory rate and blood pressure can lead to complications, and thus longer hospitalization along with decreased patient satisfaction.

Prolonged Thunder Before The Storm – Diagnosis Of Aortobronchial Fistula After 28 Months Of Recurrent Hemoptysis, Hilamber Subba, Truc Ta, Edmund Sears

Costas T. Lambrew Research Retreat 2021

Aortobronchial fistula (ABF) should always be considered in patients with hemoptysis and previous thoracic surgery, however the diagnosis is known to be difficult both clinically and radiographically1. We present a case with the longest indolent course of hemoptysis reported to date .

Would Surgeons Opt For Polypropylene Mesh If They Hypothetically Had Stress Urinary Incontinence Or Pelvic Organ Prolapse?, William J. Devan, Sanchita Bose, Dayron Rodriguez, Ricardo Munarriz, Linda Ng

Costas T. Lambrew Research Retreat 2021

Introduction

• Controversy surrounding vaginal mesh kits

• Many patients have negative connotations regarding mesh

• If patients were shown that their surgeons would opt for mesh –maybe this would help lessen the negativity?

The Introduction Of A Multimodal Clinical Pathway For Outpatient Total Knee Arthroplasty In The Era Of Covid-19, D Bunch, R Mountjoy, G Korsunsky, A Rana, C Sturgeon

Costas T. Lambrew Research Retreat 2021

The combination of a short acting spinal and muscle-sparing regional blocks, including adductor canal and iPACK blocks, can allow for successful outpatient total knee arthroplasty.

Anterior-Based Muscle Sparing Approach For Total Hip Arthroplasty, Callahan M. Sturgeon, George M. Babikian, Brian J. Mcgrory, Adam J. Rana

Costas T. Lambrew Research Retreat 2021

A high value, high quality and low cost surgery: a 7.5 year single-center, retrospective case series

Collaborative Strategies To Reduce Incomplete Operating Room Instruments Trays, Richard Neusch, Nicole Wagner, Colby Fike, Suneela Nayak

Operations Transformation

In an academic tertiary medical care center, the OR was receiving incomplete instrument trays. This issue became increasingly problematic in wasted staff time and cost to the institution.

Using a tracking system to generate a missing instrument report, baseline metrics were established. Reviewing each report, an interdepartmental team comprised of members of the OR and sterile processing departments, initiated a number of countermeasures.

Since the start of these countermeasures, there has been a reduction in the receipt of incomplete OR trays. Next steps include creating a tag process by which the OR instrument trays from one case would be kept …

Ruptured Splenic Hemangioma Presenting As Small Bowel Obstruction: A Case Report, Haya S. Raef, Karin L. Cole Md

Journal of Maine Medical Center

Introduction: Splenic hemangioma is a rare vascular tumor of the spleen. Typically asymptomatic, these lesions can present with rupture and hemoperitoneum. Clinical Findings: We report the case of a patient with no previous abdominal surgery that presented with symptoms and imaging consistent with small bowel obstruction (SBO), and an incidental finding of a splenic lesion. Main diagnoses, therapeutic interventions, and outcomes: At diagnostic laparoscopy, a ruptured splenic hemangioma was identified, with obstructive ileus due to hemoperitoneum. The patient subsequently underwent splenectomy to prevent recurrent bleeding. Conclusions: Splenic hemangiomas are rare vascular neoplasms of the spleen, which can be complicated by …

A Primer On Cognitive Errors Illustrated Through The Lens Of A Neurosurgical Practice, Jeffrey Evan Florman, Lisa Almeder, Robert Trowbridge

Journal of Maine Medical Center

Problem Statement:

Diagnostic error is often attributed to cognitive errors, including biased thinking patterns, rather than knowledge or data limitations, and education on cognitive bias deserves review in all spheres of practice.

Background:

The cognitive biases of practitioners create an inherent fallibility in recognizing and treating medical conditions. Awareness of cognitive errors is valuable for mitigating risk of diagnostic error.

The impact of cognitive error is substantial in the management of neurosurgically relevant disease. Remarkably broad differential diagnoses often accompany neurologic symptoms. Both focal and non-focal symptoms lend themselves to diagnostic inertia that contributes to errors. Further, initial diagnostic direction …

Cardiovascular: Outcomes And Innovations Report, Maine Medical Center

Annual Reports

2020 Annual Report

Increasing First Case On Time Starts In An Ambulatory Surgery Center, Diane Fecteau, Shannan Reid, Sydney Green, Ruth Hanselman, Suneela Nayak, Stephen Tyzik, Amy Sparks

Operations Transformation

In an ambulatory surgical center, first case on-time starts directly affects the patient experience. In addition, in order to treat as many patients as possible, delays of first case on-time starts negatively impacts the rest of scheduled surgical patients and increases staff overtime expenditures. An ambulatory surgical team within a large urban health care system initiated a performance improvement initiative to enhance the patient experience, increase staff accountability and care team well-being.

The goal of this project was to start 70% or more first cases on time. Baseline metrics demonstrated that patients and surgeons were the largest cause of delay. …

Changing The Surgical Residency: A Mixed-Methods Study Of Residents’ And Faculty Experiences One Year After Implementation, Sarah B. Cairo, Wendy Craig, Caitlin Gutheil, Paul K. J. Han, Kristiina Hyrkas, Lynda Macken, Jim Whiting

Journal of Maine Medical Center

Objective: To evaluate a reformed surgical residency curriculum aimed at addressing emerging practice models, enhancing residents’ educational experience, and improving the quality/continuity of patient care by reducing the service size and enhancing attending-resident interactions.

Methods: A mixed-methods study of the surgical training program following curriculum reform including: 1) focus group and individual qualitative interviews with residents, attendings, nurses, and advanced practice providers to explore stakeholder perspectives on curriculum reform, 2) time study of surgical resident activities, and 3) quantitative assessment of surgical case logs.

Results: Qualitative interviews demonstrated disparate knowledge and attitudes regarding the goals of the curriculum with emergence …

Predictors For Discharge After Robotic Hysterectomy – A Retrospective Analysis, Heidi Fox, Kristiina Hyrkas

MaineHealth Maine Medical Center

Introduction:

Hysterectomy is one of the most common surgeries performed in the United States with more than 600,000 procedures annually . It has been estimated that in 2011, there were more than 64,000 surgeries performed in an outpatient setting. The highest rate of 0.46% (464/100,000 adult women) has been reported in Maine. The average length of stay was 0.65 days for laparoscopic and 0.79 days for vaginal hysterectomies [1]. Traditionally, hysterectomies have been performed as an inpatient procedure to manage postoperative pain and monitor complications such as bleeding, anemia and return of bowel function. Development of minimally invasive surgery techniques …

Increasing Doses Of Intraoperative Hydromorphone Do Not Reduce Postoperative Pain, Craig S. Curry, Michael B. Henry, Wendy Craig, Janelle M. Richard, Denham S. Ward

MaineHealth Maine Medical Center

Introduction:

• Intermediate and long acting opioids are given intraoperatively to reduce pain during emergence from anesthesia.

• Recent evidence suggests that intraoperative opioids have inconsistent effects on nociception and pain in the immediate postoperative period.

• Multiple potent, short-acting opioids such as remifentanil, sufentanil and fentanyl have been shown to produce dose-related increases in pain scores and opioid consumption in the immediate postoperative recovery period.

• Intraoperative doses of longer acting opioids such as morphine and methadone6 have been shown to reduce pain scores and narcotic requirements in the immediate postoperative period.

• Hydromorphone is an intermediate duration narcotic …

Feasibility Of Pre-Operative Mtor Inhibitor Sirolimus In Children And Young Adults With Desmoid Tumor, Stephanie Verwys, Clara Magyar, Kathleen Glick, Douglas Hawkins, Archana Sharma, Brenda Weigel, Katherine Chastain, Joseph Khoury, Michele Manalang, Sarah Dry, Noah Federman, Aaron Weiss

MaineHealth Maine Medical Center

Background:

• Desmoid tumor represents an intermediate grade neoplasm with a striking predilection for locally invasive growth and recurrence following resection

• More effective, well-tolerated non-surgical treatment options are needed

• Current approaches

• If feasible, watchful waiting is the preferred approach

• 20-30% spontaneous regression

• In situations where treatment is indicated, the following approaches are utilized

• Surgery is the primary approach if minimal morbidity is anticipated

• Medical therapies

• Cytotoxic drugs

• Tyrosine kinase inhibitors

• Hydroxyurea

• Gamma secretase inhibitors

• mTOR Inhibitor Rationale

• Desmoid tumor is well-known to be associated with deregulation of …

Potential Of Vascular Endothelial Growth Factor As A Biomarker Of Coronary Artery Disease In Subjects Undergoing Cabg Surgery, Teaka Jackson, Sarah Peterson, Amanda Favreau-Lessard, Joanne Burgess, Susan Bosworth-Farrell, Robert S. Kramer, Douglas B. Sawyer, Sergey Ryzhov, Michael P. Robich

MaineHealth Maine Medical Center

Introduction:

• Coronary artery disease (CAD) causes local hypoxia due to reduced blood flow

• Hypoxic conditions are known to induce vascular endothelial growth factor (VEGF) production, a key contributor to angiogenesis

• The purpose of this study was to determine the potential of VEGF as a marker of myocardial stress in subjects with CAD undergoing coronary artery bypass grafting (CABG) surgery