American journal of surgery
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Biography Historical Article
Hume Memorial Lecture. Surgeon's response to battlefield vascular trauma.
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The incidence of postoperative wound complications and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immediate reconstruction were younger and had less advanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0.05) in patients with and without reconstruction, respectively. ⋯ There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immediate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complications associated with the procedure, especially if an implant is used.
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To collect information on the rapid application of laparoscopic surgery, the National Laparoscopic Surgery Registry surveyed more than 4,000 of the 16,000 currently practicing laparoscopic surgeons. Preliminary analysis of the data has revealed that most of the respondents had been trained in general surgery, but a small percentage were certified only in surgical subspecialties. Surgeons acquiring skills in laparoscopic surgery had various levels of experience ranging from less than 1 year to more than 38 years in surgical practice. ⋯ Advances in mechanical retraction may eliminate the need for carbon dioxide insufflation of the abdomen. Tissue repair using tissue glues or laser-mediated processes may reduce the need for endocavitary suturing. These advances in technology and techniques may reduce the morbidity and mortality of these surgical procedures and, ultimately, improve the standard of care for surgical patients.
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Teaching technical skills is one of the most important tasks of a surgeon. This article discusses current issues in teaching and testing technical skills. For the most part, the level of technical skills cannot be predicted before a surgical resident starts a program. ⋯ A methodologic framework for skill acquisition, adapted from the educational psychology literature, is discussed. Five methods of assessing technical skills are presented. Structuring the assessment process has resulted in higher levels of reliability and improved validity.
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The impulse to catalogue injuries is as old as human history, but the actual measurement of injury severity began only 40 years ago. The rapid development of objective measures for trauma required enormous investments of time and money to accrue large enough data bases to validate these measures. Tools are now available to measure both physical injury (injury severity score) and physiologic injury (revised trauma score), as well as their synergistic combination into the probability of survival score, and these tools are in everyday use at most trauma centers. ⋯ The current injury severity scoring system is based on clinically assigned injury severity rather than measured outcome, and considers only one injury per body region. Both of these shortcomings should be addressed. The advent of large computerized data bases will facilitate this process.