Tension-free thyroidectomy (TFT)

In this video, we present a new method of tension-free thyroidectomy (TFT). The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of isthmus and successive complete dissection of Berry's ligament. The operation was performed under general anesthesia with endotracheal intubation. Patients were placed in a supine position without neck extension. A 35-40 mm horizontal skin incision was made 1 cm above the sternal notch. Subcutaneous fat and platysma muscle were dissected. The linea alba was incised longitudinally for 4–5 cm. When the isthmus capsule was exposed, the last was divided in the middle. Full mobilization of the isthmus and thyroid lobe from the trachea by dissecting the Berry's ligament was performed. Intermitted neuromonitoring (5 mA, Inomed C2) was used to guide the division of fibers of the Berry's ligament. By using the pinnate the thyroid lobe was retracted into the lateral direction (only lateral traction of the thyroid lobe was used during the operation). The mobilization of the thyroid lobe from the trachea was completed by the division of small branches of the inferior thyroid artery and vein. The main branch of the inferior thyroid artery and vein were preserved along with the vessels supplying the parathyroid glands. After complete separation of the thyroid lobe and inferior thyroid vessels from the trachea the recurrent laryngeal nerve was identified and dissected. Also from the medial side, the upper and lower parathyroid glands and their vessels were identified and fully separated from the thyroid capsule. The lower pole of the lobe was pulled out of the thyroid bed. Finally, after neuromonitoring of the superior laryngeal nerve, the upper pole vessels were dissected and divided. In case a total thyroidectomy the same procedure was performed on the contralateral side after vagus stimulation (V2).

Sliding Osseous Genioplasty and Coronoidectomy in a Patient with Treacher-Collins Syndrome

Contributors: Andrew Weaver and Kumar Patel, PA-C 18 y.o. female with Treacher-Collins syndrome (patients have micrognathia, underdeveloped facial bones, particularly the cheek bones, and a very small jaw and chin. She is only able to open her mouth to 20mm due to the interference of her coronoid process with her zygoma/ DOI: http://dx.doi.org/10.17797/959yiezvoo

Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3 Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior. Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children's Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management. Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy. First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue. She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children's Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

Laser Supraglottoplasty

Laryngomalacia is the most common laryngeal anomaly affecting newborns. Patient's with severe disease should be considered for supraglottoplasty. It classically presents in a newborn with high-pitched inspiratory stridor that worsens with exertion, supine-positioning, and feeding. It is characterized by anatomic and physiologic abnormalities including shortened aryepiglottic (AE) folds, small, tightly curled epiglottis, redundant soft tissue overlying the cuneiform or accessory cartilages and reduced laryngeal tone. Any combination of these may present with laryngomalacia. Most cases are mild and resolve with observation or medical therapy. Steps: 1. Laser precautions are taken to protect patient and personnel. 2. Spontaneous ventilation 3. Suspension laryngoscopy is performed with adequate visualization of the larynx. 4. The operating telescope or microscope is used for visualization. The CO2 laser is tested. 5. First, division of the AE folds is performed. 6. Next, redundant mucosa and tissue overlying the accessory cartilages is ablated.

Injection Laryngoplasty for Type 1 Laryngeal Cleft

Schools: Children's Hospital of Pittsburgh Injection Laryngoplasty for type 1 laryngeal cleft is done with first identifying the deep cleft by palpation of the interarytenoid notch. Once a confirmation is made the larynx is suspended with a laryngoscope. Radiesse voice gel is then primed in a laryngeal needle and the needle is placed at the apex of the cleft. The needle is then pushed to palpate the cricoid cartilage with the bevel of the needle pointing towards the esophageal surface. The needle is then slightly retracted and about 0.2 ml of voice gel is injected. Care is taken not to make multiple punctures and the subglottisis watched so that the injection does not inadvertently go into subglottis. DOI: http://dx.doi.org/10.17797/g5r116zy3n

Costochondral Graft Harvest for Laryngoplasty

Rib cartilage is the workhorse autogenic material for laryngeal airway expansion surgery.  Most usually one will use the right-sided 5th or 6th rib as the donor site.  A 2.5 cm incision is made directly over the rib, in the inframammary crease from the lateral aspect of the nipple to the sternal xyphoid process.  Subcutaneous fat is removed.  The overlying intercostal muscles are dissected up away from the rib, divided, and retracted-- effectively exposing the rib.  Perichondrium is sharply incised on the superior and inferior borders of the rib.  A posterior tunnel is elevated in asub-perichondrial plane using blunt instruments, just medial to the osseocartilagenous (OC) junction.  A Doyen elevator is inserted into the tunnel and the rib is transected right at the OC junction.  The rib is then elevated from lateral to medial in the subperichondrial plane. Such a manuever ensures that the plueral space will not be entered, protecting the pleural membrane from injury. Once the rib has been elevated to the sternal attachment, it is completely released.  The pleura is inspected directly to confirm it has not been injured.  The wound is filled with normal saline and 30 cm of water pressure valsalva is applied by the anesthesiologist for 30 seconds, to ensure no air is escaping the lung.  The wound is closed in layers over a rubber band drain placed in a dependent position. One should be able to harvest 2.5-3 cm of cartilage. Post-operatively a chest radiograph is obtained to rule out pneumothorax DOI: http://dx.doi.org/10.17797/2jra6vjlud

Robotic Rectal Dissection; Total Mesorectal Excision (TME)

Robotic rectal dissection begins posteriorly in total mesorectal excision plane (TME) using 30° down-viewing scope. Posterior dissection in a TME plane provides a relatively bloodless plane of dissection and creates an anatomical reference point from which lateral and anterior dissection can proceed. With an assistant retracting the rectum anteriorly and cephalad, the robotic single fenestrated grasper retracts the posterior aspect of the mesorectum anteriorly and slightly caudally. When performed correctly the surgeon can visualize a “cotton candy”-like areolar tissue between the fascia propria of the rectum and presacral fascia. The hook cautery is used to divide the tissue in a U-shaped fashion. The dissection is taken to the level of Waldeyer’s fascia. Lateral Dissection and Division of Lateral Stalks The lateral dissection proceeds initially on the right side where the surgeon has a safer plane of dissection (away from left ureter). A monopolar hook moves from posterior to anterior at a deliberate pace while applying current. If the right and posterior dissection was performed correctly, the only structures that need to be divided on the left side are a layer of peritoneum and a small amount of remaining lateral stalks. The left lateral side is dissected by dividing the peritoneum over the left pararectal sulcus. The left ureter must be visualized during this step. It is important to control all vessels, even the ones that appear to be only mildly oozing. Failure to do so may result in the field becoming bloody and dark. In this video, a vessel, encounterd within the left stalk is coagulated using a bipolar grasper while retracting the mesorectum with the hook. After the vessel is sealed it is divided with hook cautery. Anterior Dissection As the dissection advances inferiorly, the right and left lateral peritoneal incisions that are created during lateral dissection at this point are connected in front of the rectum. At this stage in operation, with the switch to a 0° scope and change of the retraction of the rectum from anterior and cephalad to posterior and cephalad, the rectum is pulled straight out of the pelvis. Because the posterior dissection has now released the mesorectum, the rectum can be easily stretched placing under tension the anterior plane of dissection. Circumferential Dissection of the Rectum If the rectal cancer is distal within the rectum, the mobilization proceeds to the level of pelvic floor and occasionally performing some dissection within the levator muscle complex. As the surgeon advances towards the pelvic floor, the dissection alternates between the posterior, lateral and interior planes as the tissue tension changes based on dissection performed. One of the signs that the dissection is at the level of pelvic floor is observation of levator ani skeletal muscle fibers that contract upon contact with electrocautery and the tapering of the mesorectum. As it narrows at the level of pelvic floor, the rectum can be carefully grasped with a robotic grasper and retracted to obtain the necessary tension to provide dissection. Editor Recruited By: Jeffrey B. Matthews, MD DOI: http://dx.doi.org/10.17797/4bvv6oyrym

Choanal Atresia Repair

Contributor: Tyler McElwee Choanal atresia describes the congenital narrowing of the back of the nasal cavity that causes difficulty breathing in neonate. Choanal atresia is often associated with CHARGE, Treacher Collins and Tessier Syndrome. It is a rare condition that occurs in 1:7000 live births, seen in females twice as often as males, and affects bilaterally in roughly 50% of cases.  Bilateral choanal atresia is usually repaired in the newborn period. Unilateral CA repair is often deferred until age 2-3 years. Stent placement has become optional as stentless repair is gaining popularity because this technique decreases foreign body reaction in the nasopharynx which in term decreases granulation formation.  Transnasal endoscopic choanal atresia repair is performed by opening the atresia bilaterally, drilling out pterygoid bone as needed, and removal of the posterior septum and vomer. Normal mucosa is preserved as much as possible by elevating a lateral based mucosal flap to prevent scarring and restenosis. Postoperatively, these patients are treated with antibiotic, reflux medications and steroid nasal drops; a second look procedure is planned 4-6 weeks postop for debridement and possible removal of granulation tissue & scar. DOI: http://dx.doi.org/10.17797/9s5ty2f7yv Editor Recruited By: Sanjay Parikh, MD, FACS

Bilateral Dacryocystoceles Resection

Contributor: Tyler McElwee Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst.  The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants.  It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction.  It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates.  Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions.  Ultrasound, CT scan or MRI can be used for diagnosis.  About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing.  The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele.   Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement.  Post-operatively patients are treated empirically with antibiotics and nasal saline.  No second look is usually planned unless patients develop significant nasal obstrctuion. Editor Recruited By: Sanjay Parikh, MD, FACS DOI: http://dx.doi.org/10.17797/16rnuq8n0y

Routine Laparoscopic Ultrasound During Laparoscopic Cholecystectomy

Laparoscopic ultrasound (LUS) is a simple and reliable method for evaluating the common bile duct (CBD) during laparoscopic cholecystectomy. It is particularly useful for identifying the location of the CBD and common hepatic duct (CHD) during difficult operative circumstances when the anatomy is obscured. LUS can be performed prior to any potentially hazardous dissection and can easily be repeated as necessary to safely guide dissection. This brief video demonstrates the technique of LUS during routine LC. A flexible tip probe with a multi-frequency, side viewing, curvilinear transducer is used. Scanning is typically performed at a frequency of 10 MHz. During intraoperative applications, the ability to place the transducer in close contact with the tissue being examined allows use of a higher frequency transducer. Higher frequency ultrasound waves yield better resolution than the lower frequencies that are necessary for adequate depth of penetration during transabdominal imaging. Fluid is instilled over the hepatoduodenal ligament to improve acoustic coupling. The ultrasound probe, covered by a sterile sheath, is introduced through a 10 mm sub-xiphoid port. The probe is extended to the patients’ right side and then angled to 90 degrees. The bend is maneuvered under the lateral segment of the left liver so that the transducer can be positioned over the hepatoduodenal ligament with light contact. Scanning is started in a plane transverse to the hepatoduodenal structures. The normal anatomic landmarks are described as depicted in the sonographic image on the video. The junction of the cystic duct with the CBD is identified. The proper hepatic artery (HA) is to the right of the CBD on the screen. The portal vein (PV) is dorsal (“posterior”). The cross sectional image of the PV, HA and CBD together create a “Mickey Mouse” pattern with the cartoon characters’ circular head (PV) below and ears (CBD & HA) on top. The CBD is traced caudally to the duodenal ampulla which is well seen. This is accomplished by subtle rotation of the operators’ wrist. The internal diameter of the CBD is measured to be 4 mm (normal upper limit 6-7 mm). If present, stones are readily visualized as echogenic structures with posterior acoustic shadowing and sludge as echogenic material without shadowing. The CBD is traced cephalad and the transducer is rotated to yield a longitudinal view of the CBD and PV which appear as parallel tubular structures. In this plane, the right hepatic artery appears as a round structure and is most typically located dorsal to the CHD. Doppler can demonstrate the characteristic waveforms of the vascular structures, although it is not usually necessary for identification. The PV has a low velocity, continuous forward flow with minor undulations due to cardiac activity. Flow in the inferior vena cava is bi-directional due to the cardiac cycle and respirations. The HA demonstrates features of a low resistance type vessel with a bi-phasic spectral waveform that continues forward during diastole. The CBD has no Doppler signal other than the interference from respiratory excursion. The aorta and right renal artery are also seen at the inferior aspect of the sonographic images. When the examination has been completed, the flexible probe is straightened and withdrawn under direct vision. DOI: http://dx.doi.org/10.17797/njy9uc14u2 Editor Recruited By: Jeffrey B. Matthews, MD

Fascia with Bone Pate Resurfacing Technique for Repair of Superior Semicircular Canal Dehiscence

Contributors: Jacob B. Hunter, Reid C. Thompson and David S. Haynes Superior semicircular canal dehiscence (SCD) is a condition in which the bone overlying the superior semicircular canal is absent. The clinical presentation of SCD is highly variable and may include both auditory and vestibular manifestations. The more common symptoms include autophony, sound or pressure induced vertigo, hypersensitivity to sound, and low frequency conductive hearing loss. Repair can be accomplished via either transmastoid or middle fossa approaches, with numerous materials used to either plug or resurface the canal. Herein, we describe our resurfacing technique using a loose areolar tissue-bone pâté-loose areolar tissue sandwich through a middle fossa approach. DOI#: http://dx.doi.org/10.17797/kcwvab3b7r

Rib Cartilage Harvest for Laryngotracheal Reconstruction

Contributors: Deepak Mehta This video depicts how to harvest a rib cartilage graft for use in pediatric laryngotracheal reconstruction for airway stenosis. DOI# http://dx.doi.org/10.17797/oo77838cxt Authors Recruited By: Deepak Metha

Alopecia Excision and Repair

Contributors: Michael Golinko  and Kumar Patel Removal of an approximately 5 cm congenital alopecia using an O to Z or yin-yang flap method. DOI: http://dx.doi.org/10.17797/rbbu00mhp0

Bilateral Cryptotia Repair

Contributors: Shira Koss 6 year old boy suffering from bullying at school as a result of bilateral cryptotia, a very unusual congenital ear anomaly in which the superior helix is buried under temporal skin. DOI#: http://dx.doi.org/10.17797/le4g6c5rk5

Congenital Nasal Pyriform Aperture Stenosis (CNPAS): Sublabial Approach to Surgical Correction

Congenital nasal pyriform aperture stenosis (CNPAS) is defined as inadequate formation of the pyriform apertures forming the bony nasal openings resulting in respiratory distress and cyanosis soon after birth. Some clues such as worsening distress during feeding and improvement during crying may indicate a nasal cause of respiratory distress rather than distal airway etiology. Inability or difficulty passing a small tube through the nasal cavities may suggest CNPAS. The presenting clinical features of CNPAS can be similar to other obstructive nasal airway anomalies such as choanal atresia. Diagnosis is confirmed via CT scan with a total nasal aperture less than 11mm. CNPAS may occur in isolation or it may be a sign of other developmental abnormalities such as holoprosencephaly, anterior pituitary abnormalities, or encephalocele. Some physical features of holoprosencephaly include closely spaced eyes, facial clefts, a single maxillary mega incisor, microcephaly, nasal malformations, and brain abnormalities (i.e. incomplete separation of the cerebral hemispheres, absent corpus callosum, and pituitary hormone deficiencies). It is important to rule out other associated abnormalities to ensure optimal treatment and intervention. Conservative treatment of CNPAS includes humidification, nasal steroids, nasal decongestants and reflux control. Failure of conservative treatment defined by respiratory or feeding difficulty necessitates more aggressive intervention. The most definitive treatment for CNPAS is surgical intervention to enlarge the pyriform apertures. Contributors: Adam Johnson MD, PhD Abby Nolder MD

Endoscopic Management of a Type IV Branchial Cleft Anomaly

Trans-oral endoscopic approach to exposure of a type IV branchial cleft anomaly sinus tract in the left piriform recess and closure using cauterization and tisseel application. Co-author: Yi-Chun Carol Liu

Split Thickness Skin Graft

Skin grafting involves closure of an open wound using skin from another location which is transferred without its own vascular blood supply, relying on the vascular supply of the wound bed for survival. Skin grafts can be split thickness grafts that may involve meshing the donor skin in order to cover a proportionally larger area than the donor skin may have allowed. Besides the ability to cover a large area, a split thickness skin graft (STSG) allows for egress of fluids thereby maximizing close contact between the wound and the graft, which is necessary for vascularization and survival of the graft. A STSG can be taken at a variety of thicknesses but at any level taken, part of the donor dermis is left intact. Other options for skin grafts include full thickness grafts and biomedical grafts such as Integra. Full thickness skin grafts (FTSG) take the dermis as well as epidermis, usually covering smaller areas. FTSG has reduced contracture and often a better color match compared to STSG, but can have reduced survival due to increased thickness of tissue. The decision of the type of graft used in the procedure is made in accordance with the needs of the recipient site, the likelihood of graft take, and the availability of donor skin. The patient may either go home after the procedure with small areas of skin grafting with instructions for immobilization and elevation of the grafted area. The patient may be admitted depending on the patient’s general health status and the wound. Shear forces are avoided to the grafted area, and the donor site dressings may require prn changes due to fluid leakage until the skin epithelium regenerates from residual dermal structures. In the case presented in this video, a 12 year old girl was victim to a degloving injury of the left dorsal foot secondary to a motor vehicle accident. A STSG was determined appropriate for wound coverage as her wound bed had granulated in very well, covering all critical structures and providing a healthy bed for graft take. Linda Murphy MA Roop Gill, MD

Endoscopic Grade 4 Subglottic Stenosis

We describe the management of a grade 4 subglottic stenosis, which was successfully performed endoscopically. This is the case of a 17 year-old female, tracheostomy dependent, with a complex history of failed open airway surgeries. Patient was referred to our center for a second opinion for decannulation. We found a grade 4 subglottic stenosis at her initial evaluation with a prolapsed anterior graft. Patient and family requested an endoscopic procedure, trying to avoid another open surgery. It was decided that an endoscopic procedure would be attempted. Patient was placed into suspension, and using alligator forceps, the stenotic area was probed until communication could be made with the distal tracheal. Using a series of balloon dilations and the microdebrider, a suprastomal stent could be endoscopically placed. Stent was removed 6 weeks later and showed a patent airway. Patient then underwent a series of 4 dilations and was successfully decannulated, just before graduating from college.

Total Calvarial Reconstruction for Increased Intracranial Pressure and Chiari Malformation

This procedure is a total calvarial vault expansion to correct pansynostosis in a three-year-old child. Total calvarial reconstruction is an open procedure that consists of removing bone flaps with an osteotome, outfracturing the skull bone edges with a rongeur to allow for future expansion, shaving down the bone flap inner table with a Hudson brace to create a bone mush for packing the interosseus spaces, and modifying then reattaching the bone flaps with absorbable plates and screws. This patient is status post craniofacial reconstruction for earlier sagittal synostosis. Second operations are uncommon after correction of single-suture synostosis, so this more aggressive technique represents an attempt to definitively correct the calvarial deformity and resolve the signs and symptoms of the attendant intracranial hypertension. Indications for surgery include cosmetic and neurologic concerns, here including a Chiari malformation and cervicothoracic syrinx. This educational video is related to a current research project of the Children’s National Medical Center Division of Neurosurgery regarding single-suture craniosynostosis and the factors that place children at risk for surgical recidivism in the setting of intracranial hypertension. Kelsey Cobourn, BS - Children's National Medical Center Division of Neurosurgery and Georgetown University Owen Ayers - Children's National Medical Center Division of Neurosurgery and Princeton University Deki Tsering, MS - Children's National Medical Center Division of Neurosurgery Gary Rogers, MD, JD, MBA, MPH - Children's National Medical Center Division of Plastic and Reconstructive Surgery and George Washington University School of Medicine Robert Keating, MD - Children's National Medical Center Division of Neurosurgery and George Washington University School of Medicine (corresponding author)

Upper Eyelid Blepharoplasty

Introduction: Cosmetic Upper Blepharoplasty involves removing excess skin from the upper eyelid to enhance the appearance of the upper eyelids. Methods: Markings were made for the inferior incision on the upper eyelid between 8-10 mm above the upper lash line. Forceps are used to pinch the excess upper eyelid skin in the middle, nasal, and temporal, aspects of the upper eyelid. Markings are then made superiorly at the middle, nasal, and temporal points and are connected. Toothed forceps are used to pinch the excess upper eyelid skin, using the markings as a guide. Iris scissor is used to excise the pinched excess skin and the underlying orbicularis muscle. The skin between the two eyelids was closed. Conclusions: In our experience, cosmetic upper blepharoplasty is an efficient way to enhance the appearance of the eyes. By: Peyton Yee, Addison Yee Surgeon: Suzanne Yee, MD, FACS Dr. Suzanne Yee Cosmetic and Laser Surgery Center, Little Rock, AR, USA Recruited by: Gresham T Richter, MD

Trabeculectomy

Aqueous humor is drained from the eye via the trabecular meshwork or the uveoscleral pathway. Trabeculectomy is performed to lower intraocular pressure in glaucoma patients by means of creating an ostium in the anterior chamber connected to a partial thickness scleral flap covered by conjunctiva. This allows aqueous humor to be filtered into the subconjunctival space and out of the eye via the venous system. Procedure First, a partial thickness traction suture using a 6-0 Vicryl is passed through the superior cornea to rotate the eye inferiorly and expose the superior quadrant. Sharp curved Vannas scissors and 0.12 forceps are used to create a conjunctival limbal peritomy superiorly at the 3 o’clock hour position. The peritomy may be placed near the limbus or fornix. Mini Westcott scissors are then used to bluntly dissect and undermine the conjunctiva and Tenon’s layer to expose the sclera posteriorly, nasally, and temporally. Hemostasis can be achieved with light cautery. Three instrument wipe sponges are soaked with 0.4 mg/m of mitomycin C and then placed underneath the conjunctiva and Tenon’s layer and superior to the sclera nasally and temporally. They are left for 90 seconds and subsequently removed. Any remaining mitomycin C is irrigated with BSS. Next, the eye is rotated inferiorly, and a #67 blade is used to create a 3.5 mm x 3 mm triangular scleral flap hinged at the limbus of about 50 to 75% thickness. Various shapes of the scleral flap can be made depending on surgeon preference (rectangular, trapezoidal etc.). Straight tying forceps are used to lift the apex while a #67 blade is used to dissect beneath the flap anteriorly until the blue-gray zone of the limbus is exposed. At this point, a crescent blade is used to create a tunnel beneath the flap into the peripheral clear cornea. An anterior chamber paracentesis is created. An MVR blade is used to enter the anterior chamber through the tunnel and the sides of the blade are used to enlarge the opening. A Kelley-Descemet punch is used to excise a corneal/trabecular block at the posterior lip of the wound until a clear ostium is observed under the flap. Colibri forceps are used to grasp and prolapse the peripheral iris tissue. An iridotomy is then performed using curved Vannas scissors. The anterior chamber is re-inflated with BSS. A 10-0 nylon suture is then used to close the scleral flap with one suture at the apex and another at each base of the flap. The flap should be closed tightly enough to ensure the anterior chamber remains formed but loose enough to allow for drainage. Only the apical suture should be sealed most tightly to allow easier suture removal if the flap is too tight. Although not featured here, BSS can be injected through the paracentesis, and the flap confirmed to be watertight. 10-0 Vicryl is then used to close the conjunctiva against the limbus, forming a tight seal. The traction suture is then removed. At the conclusion of the case, subconjunctival injection of antibiotic and/or steroid can be given inferiorly. The anterior chamber should be formed and intraocular pressure appropriate. Wound leakage should be inspected with digital palpation. Indications Trabulectomy is indicated in glaucoma with uncontrolled intraocular pressures and progressive nerve injury refractory to maximal or tolerable medication management that is causing visual disability. Cost, compliance, side effects, inconvenience, and other factors should be considered when weighing the risks and benefits of trabeculectomy. Consideration should be made when glaucoma is moderate to advanced in severity, rapidly progressive, or failed prior laser surgery. Contraindications Contraindications to trabulectomy are limited life expectancy, medical comorbidities that enhance the risks of undergoing surgery, and scarring of the superior conjunctiva. Benefits should outweigh risks of the procedure. Setup Patient is prepared and draped in the usual sterile fashion for cataract surgery. Retrobulbar block can be administered. Preoperative Workup The patient’s glaucoma stage and type are identified. History taking should involve asking patients about trauma, prior eye surgeries, bleeding disorders, intake of blood thinners or aspirin, and inflammation or infection. A complete ophthalmic examination is performed, including intraocular pressure and assessment of the angles under gonioscopy. Nerve OCTs and Humphrey visual fields are also obtained. No bloodwork, EKG, or imaging are required. Anesthesia questionnaire is completed prior to the procedure. Anatomy and Landmarks The following anatomic structures should be identified: conjunctiva, Tenon’s, sclera, and iris. It is important that the flap consist of 50-75% scleral thickness. The traction suture should be placed in the superior cornea and the peritomy created at the 3 o’clock hour position. Advantages/Disadvantages IOP control, defined as IOP < 21 mmHg and reduction at least 20% from baseline, was maintained over 5 years on average after surgery [1]. Failure rates in a study that followed patients for 3 years were 13.9% at 1 year, 28.2% at 2 years, and 30.7% at 3 years [2]. Failure was defined as persistent hypotony or uncontrolled IOP. Complications/Risks Risk factors for trabeculectomy failure include previous eye surgeries, neovascular or uveitic glaucoma, African American ethnicity, and young age [3]. Early problems in the post-op period are elevated IOP or hypotony. Complications include bleb leak (6-11%), iris prolapse obstructing flow (1.1%), encapsulated bleb (6-12%), shallow anterior chamber (13%), ptosis (12%), serous choroidal detachment (11%), choroidal effusion (4%), new synechiae formation (5%), corneal edema (6%), endophthalmitis (3%), and suprachoroidal hemorrhage (0.7%) [2,4].

Excision of a Preauricular Cyst

Background Preauricular cysts are a subset of asymptomatic, dome-shaped lesions referred to as epidermoid cysts. Cysts vary in size and have the ability to grow in diameter over time. These cysts can occur anywhere on the body and usually contain keratin. Upon examination of a suspected cyst, different characteristics can specify its type. Dermoid cysts are typically odorous lesions found around the eyes or on the base of the nose. If the cyst did not originate from sebaceous glands, it is not deemed a sebaceous cyst. Typically, surgical intervention is required to fully remove the cyst and prevent further infections or growth.  Introduction The video shows an 18-year-old female who presented with a preauricular cyst near her left ear. Upon history and physical examination, the mass was predicted to be a dermoid cyst rather than a sebaceous cyst. Surgical recommendations were given to perform an excisional biopsy of the cyst. The excision is displayed step-wise in the video. Methods A 2 cm incision was made just posterior to the lesion with a 15 blade scalpel. Dissection was carried with a sharp hemostat down the level of the parotid fascia. A 1 cm cystic structure was found adherent to the overlying dermis. An elliptical incision was then made over the mass and it was removed with the adherent overlying skin. The wound was then irrigated. Wound was closed in 3 layers. First, the deep layer was closed with 5-0 PDS in interrupted fashion, followed by 5-0 monocryl in running subcuticular fashion, followed by Dermabond Results The patient was returned to the care of anesthesia where she was awoken, extubated, and transported to PACU in stable condition. The patient tolerated the procedure well and was discharged the same day. The specimen was sent for pathological analysis. The pathology report showed that the mass was an epidermal inclusion cyst.

Treatment of Chronic Atelectatic Middle Ear with Endoscopic Placement of Cartilage Shield T-tube

Chronic tympanic membrane (TM) atelectasis is a difficult condition with many management challenges and currently has no acceptable gold standard treatment. TM atelectasis is the loss of the normal elasticity of the TM as a result of chronic negative pressure in the middle ear and can be associated with retraction pockets. The under-ventilation of the middle ear and TM retraction can cause ossicular erosion, hearing loss, or cholesteatoma formation. Atelectasis can be halted or reversed with placement of pressure equalization tube (PET). Cartilage tympanoplasty with or without PET has been reported as the preferred material likely due to its higher mechanical stability under negative pressure changes within the middle ear, in addition to its resistance to resorption. This video demonstrates the feasibility of a minimally invasive endoscopic approach of cartilage shield T-tube tympanoplasty as a treatment of chronic TM atelectasis.

Trabectome

This is a trabectome procedure performed on a patient with moderate severity open angle glaucoma. Trabectome is a minimally invasive glaucoma surgery (MIGS) developed by Baerdveldt and Chuck where the trabecular meshwork is electrocauterized, irrigated, and aspirated under gonioscopy to improve the drainage of aqueous humor and reduce intraocular pressures. Procedure Topical TetraVisc is first administered to the eye. The patient’s head is rotated 30 degrees away from the surgeon and the microscope tilted 30 degrees toward the surgeon. The patient’s axial core can be rotated if turning the neck proves difficult. The gonioscope lens is used to visualize the trabecular meshwork, the pigmented line between Schwalbe’s line and the scleral spur. A 1.7 mm temporal clear corneal and uniplanar incision is made 2 mm anterior to the limbus. While applying continuous irrigation to deepen the angle, the Trabectome handpiece is introduced into the anterior chamber under gonioscopic visualization, and the end of the device was inserted into the inferonasal trabecular meshwork. When properly inserted, the trabecular meshwork should enter between the electrode tip and the footplate, causing the footplate to be obscured by the trabecular meshwork. The handpiece is used to ablate trabecular meshwork at a setting of flow 3 and 0.7 mW. It is rotated superiorly to create a 120 degree cleft, exposing the outer white wall of Schlemm’s canal. Care must be taken to prevent outward push on Schlemm’s canal by applying a slight inward pull during ablation. The handpiece may need to be readjusted as it is rotated in a counter-clockwise fashion. The handpiece is removed from the anterior chamber. The patient’s head is returned to a neutral position, and BSS was used to exchange viscoelastic from the anterior chamber through the temporal wound. BSS is to irrigate red blood cells from the Schlemm’s canal collector channels. The gonioscope is used to verify the cleft. At the conclusion of the case, the intraocular chamber is formed and pressure checked to be appropriate via digital palpation. Indications Trabectome is indicated for narrow-angle [1], open-angle, and secondary glaucoma with uncontrolled intraocular pressures and progressive nerve injury refractory to maximal or tolerable medication management [2]. As a MIGS, trabecome can be considered in initial stages of glaucoma due to its safety and quick routine recovery. Reduction of drops due to side effects, costs, or poor compliance are reasons to offer this procedure to patients [3]. Trabectome surgery can also be performed in conjunction with cataract surgery, in pseudophakic and phakic eyes, and after trauma, scleral buckle [4], laser trabeculoplasty [5], or failed trabeculectomy or tube shunt [6,7]. Contraindications Contraindications are few but the most common is pathology that limits gonioscopic view of the angle (active neovascular glaucoma, uveitis, corneal edema etc). Setup Patient’s head is rotated 30 degrees away from the surgeon and the microscope rotated 30 degrees toward the surgeon to provide optimal surgical approach. Preoperative Workup The patient’s glaucoma stage and type are identified. History taking should involve asking patients about trauma and prior eye surgeries. A complete ophthalmic examination is performed, including intraocular pressure and assessment of the angles under gonioscopy. Nerve OCTs and Humphrey visual fields are also obtained. No bloodwork, EKG, or imaging are required. Anesthesia questionnaire is completed prior to the procedure. Anatomy and Landmark Trabecular meshwork should be identified as the pigmented line between Schwalbe’s line and the scleral spur. Care must be taken to not ablate the ciliary body band. Blood reflux from Schelmm’s canal collector channels to confirm the ablation target can be induced by burping the main incision. After ablation, the cleft should be verified. The pigmented line from the trabecular meshwork should no longer be visible and only the outer wall of Schlemm’s canal seen. Advantages/Disadvantages Numerous studies have looked at the efficacy of trabectome surgery. Intraocular pressure drops to the mid-teens and decreasing the number of medications in most cases [8]. Unlike trabeculectomy or tube shunts, there is little scarring, the conjunctiva is preserved, the recovery is predictable, and there are less complications [3]. Patients with higher IOPs stand to benefit with greater reductions in IOPs than those with lower IOPs. There is limited data on the long-term success rate of trabectome surgeries. Studies following patients after surgery show that trabectome alone has a 70% success rate at 1 year but only 22% at 2 years [9,10,11]. Complications/Risks The most common complications are transient hyphema, peripheral anterior synechiae, corneal injury, and transient IOP spikes of 10 mmHg or higher. Surgical failure can be due to incomplete or improper removal of the trabecular meshwork as well as damage to the ciliary body band or surrounding tissues [12]. The rate of serious vision-threatening complications, such as hypotony, cyclodialysis cleft, choroidal hemorrhage, and endophthalmitis, is <1% [13].

Phacoemulsification of a cataract

Phacoemulsification of a cataract Samia Nawaz, John Chancellor, and Ahmed Sallam Introduction A cataract can be simply defined as clouding of the lens of the eye. As the proteins that make up the lens of the eye harden and aggregate, a cataract forms. Cataracts are attributed to cause half of vision loss in the population and are most commonly related to age, although trauma, radiation exposure, and genetics have also been implicated. Cataracts can cause visual disturbance such as faded color perception, blurry vision, reduced night vision, and the perception of seeing halos around lights. Due to these hindrances, surgery is a common approach to alleviate the problems they cause. Phacoemulsification is a technique that uses ultrasonic waves to emulsify the dysfunctional lens, and we may then replace it with a synthetic one, clarifying vision. A 55 year old patient presented with reduced visual acuity due to a cataract in their left eye. A phacoemulsification of the cataract with implantation of an intraocular lens was performed here. Methods First, the patient’s eye was anesthetized using topical anesthetic. The patient was prepped and draped using sterile technique. A knife was then inserted into the cornea 90 degrees to the presumed incision site. This is known as the primary port incision. After this, incisions are placed 45 degrees to the presumed incision site, known as the secondary port incision. Viscoelastic was then inserted into the anterior chamber. Continuous curvilinear capsulorrhexis was performed using capsulorrhexis forceps to open the anterior capsule of the eye. We began with a central linear cut, then pulled the needle in the direction of the desired tear, allowing the capsule to fold over. We had created a flap we used to gain entry to the lens. We injected salt solution under the anterior capsule in a step called hydrodissection, allowing the fluid to decompress the anterior capsule by compressing the central part of the lens. Nuclear rotation, a step which mobilizes the nucleus and minimizes the possibility of damage to the zonular fibers or posterior capsule, was then performed. Phacoemulsification was begun after this, where ultrasonic waves broke up the nucleus of the lens into smaller pieces, thereby fragmenting the cataract and emulsifying it into a mixture to be irrigated and aspirated. We then inserted an irrigation/aspiration instrument to remove residual pieces of lens cortex. The last step was insertion of the pre-folded synthetic lens. We reformed the anterior chamber with viscoelastic, and then loaded the lens in with a cartridge. It will unfold and settle into the eye with our adjustments. We then irrigated the wound to decrease leakage by swelling up the wound edges. Results The patient was discharged the same day and followed up in clinic 1 week later. The incisions were healing well with no indications of infection or wound dehiscence. Conclusion Phacoemulsification of a cataract is a successful and widely used way of alleviating reduced visual acuity as a result of cataract formation in the eye.

RESECTION OF THE POSTERIOR GASTRIC WALL: ANOTHER STRATEGY AGAINST GIST WITH ENDOLUMINAL GROWTH

Gastrointestinal stromal tumors (GIST) occur most frequently at the gastric level. Surgical resection is the mainstay of treatment and can usually be performed using laparoscopic approaches (1). The resection strategy must be adjusted to each case, the selection of location, size and growth pattern of the tumor (2). We present the case of a 78-year-old female patient who, after going to the Emergency Department due to symptoms of upper gastrointestinal bleeding, showed a 5 cm heterogeneous tumor depending on the muscular layer itself in a posterior gastric wall, endoluminal growth, and without objectifying others injuries in the study of extension. A wide posterior resection of the gastric posterior wall and primary closure with a barbed suture was performed laparoscopically. The postoperative evolution was satisfactory. The histopathological study shows low-risk GIST (5 mitosis / 50 CGA) with free margins; during follow-up, no recurrence was observed. Simple laparoscopic resection of gastric GIST tumors seems to be a useful strategy in terms of oncological safety, reducing excessive resection of tumor-free tissue and increasing gastric remnant.

Surgical management of keratosis obturans

Keratosis obturans is a condition of the external auditory canal (EAC) characterised by formation and accumulation of desquamated keratin resulting in varying symptoms. Clinically presents as otalgia, conductive hearing loss and recurrent infection. Typically seen in younger age group and can occur bilaterally. Extension to adjacent structures can occur and result in further complications. The proposed theory is that there is a defect in epithelial in migration resulting in widening / osteitis of external canal bone. Condition was first described by Toynbee in 1850, and named by Wreden in 1874. Pipergerdes in 1980 distinguished keratosis obturans as separate disease from external auditory canal cholesteatoma. Ever since various treatment regime has been recommended but none of them have been curative. Michael M Paparella was first to propose surgical treatment in 1966 and he then modified the surgical technique in 1981. Because the defect is in epithelial migration, canaloplasty with or without graft, without obliterating the bony canal defect will not restore epithelial migration. Hence, M. M Paparella’s surgical technique was NOT popularized. Mr Basavaraj proposes novel technique which not only clears the diseased bone but obliterates the bony defect, and grafts the ear canal to bring it back to normal shape and size to encourage normal epithelial migration.

Transpalatal Advancement Pharyngoplasty

The retropalatal airway is a common site of collapse in obstructive sleep apnea. Transpalatal advancement pharyngoplasty aims to address this site of upper airway collapse by advancing the soft palate anteriorly, increasing the cross-sectional area of the airway and decreasing pharyngeal collapsibility. Surgeon: Raj C. Dedhia1, MD, MSCR Video Production: Yifan Liu1,2, MD, Jason Yu1, MD 1 Perelman School of Medicine, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania 2 Department of Otorhinolaryngology - Head and Neck, Affiliated Beijing Anzhen Hospital, Capital Medical University

Ahmed® Glaucoma Valve for Treatment of Refractory Glaucoma

Introduction Intraocular pressure is the single modifiable risk factor resulting in progression of various subtypes of glaucoma. Intraocular pressure control is often achieved with topical medications, outpatient laser procedures, or minimally-invasive glaucoma surgery (MIGS). This patient is a 63-year-old with traumatic glaucoma in the right eye with elevated intraocular pressure sub-optimally controlled despite maximum medical therapy (29 mmHg). His intraocular pressure must be controlled with incisional glaucoma surgery - in this case, with placement of an Ahmed Model FP7 glaucoma valve. An advantage of valved glaucoma shunts is lower risk of postoperative hypotony-related complications compared to non-valved glaucoma shunts. Methods The 10 and 12 o'clock meridians are marked with a marking pen to define the borders of the conjunctival peritomy. A limbal traction 6-0 Vicryl suture is placed superotemporally in the cornea at the limbus. The conjunctival peritomy is then completed using Westcott scissors along the predetermined marks. The peritomy is extended posteriorly with blunt dissection using Stevens tenotomy scissors. Wet field cautery is used to achieve hemostasis of the scleral bed. A Stevens tenotomy hook is used to identify the superior rectus muscle and a marking pen is used to mark its border. The Ahmed Model FP7 tube shunt is then introduced onto the surgical field. Balanced salt solution is injected into the tip of the tube using a 30-gauge cannula to ensure adequate patency of the valve. The Ahmed plate is then sutured to the sclera approximately 8 mm posterior to the limbus using 5-0 Nylon suture. A corneal paracentesis is made at the 8 o'clock position, and viscoelastic is injected to deepen the anterior chamber. A 23-gauge needle attached to the Healon syringe is then used to tunnel from a point 2.0 mm posterior to the limbus into the anterior chamber. The needle tract is anterior and parallel to the plane of the iris and the surgeon must ensure that the tube does not contact the iris or corneal endothelium after insertion. The implant tube is then laid flush with the cornea and shortened with Westcott scissors with an oblique cut, bevel up. Healon is injected as the needle is withdrawn. Non-toothed forceps are then used to insert the tube into the anterior chamber. A single 8-0 Vicryl suture is used to secure the tube to the underlying sclera. A corneal patch graft is cut to fit the site of tube implantation and secured with a single 8-0 Vicryl horizontal cross mattress suture. The conjunctival peritomy is then closed with a running 8-0 Vicryl suture on a BV needle. Anchoring sutures incorporating the conjunctiva and the episclera to firmly secure the corners of the peritomy to the limbus. A 9-0 Nylon suture is used to re-approximate the limbal conjunctiva. At the conclusion of the case, the eye is returned to a neutral position, the traction suture is removed, and satisfactory intraocular pressure is confirmed by palpation. Results No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and mild pain that decreased over the following week. Prednisolone acetate drops were applied six times daily to prevent inflammation and moxifloxacin drops were applied four times daily to prevent infection. At the three-month follow up, the eye was quiet and intraocular pressure was measured to be 9 mmHg. Conclusion Implantation of an Ahmed glaucoma tube shunt is a safe procedure that can effectively treat various subtypes of glaucoma with sub-optimally controlled intraocular pressure despite maximum medical therapy. Joseph W. Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Ahmed A. Sallam, MD, PhD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA ASallam@uams.edu Surgery was performed at University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Pre-operative marking for the Fisher technique in unilateral cleft lip repair

This video outlines the steps taken for pre-operative markings that need to be made prior to performing unilateral cleft lip repair using the Fisher anatomic subunit approximation technique. The technique has been written about in detail by Dr. David Fisher in his article "Unilateral Cleft Lip Repair: An Anatomical Subunit Approximation Technique". This video simply outlines the markings that are made prior to performing this technique, which are crucial for correctly carrying out the repair.

Open Tracheotomy in Ventilated COVID-19 Patients

Authors Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1 1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY *Co-First authors Overview The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team. Procedure Details The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea. Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation. Indications/Contraindications Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2

Endoscopic Assisted Aural Atresia Repair

Congenital aural atresia (CAA) is a birth defect that describes both aplasia and hypoplasia or stenosis of the external auditory canal (EAC). CAA can be associated with microtia (malformation of the pinna), middle ear and occasionally inner ear malformations. Surgical correction of CAA is a very challenging operation and requires a thorough knowledge of the surgical anatomy of the facial nerve, middle and inner ears. Traditional post-auricular approach or transcanal approach with the help of a microscope usually provides adequate images needed for the procedure. Endosocpic ear surgery provides the advantage of visualization beyond the view provided by the microscope, further refinement of the surgical approach, precise assessment of the ossicular chain mobility and placement of ossicular chain prosthesis if necessary.

Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.

Vascular Video

For a lateral tunneled catheter approach, the hockey-stick linear transducer is placed low, directly above the clavicle. The handle of the transducer is held medially, exposing the lateral end of the transducer for needle alignment, parallel to the clavicle. The internal jugular vein is seen via US, with the carotid artery lying medially. The needle is inserted in-line, beginning just lateral to the sternocleidomastoid (SCM) while being careful not to injury the nearby external jugular vein. The needle is advanced medially, below the SCM, directly into the internal jugular vein, while maintaining in-line full needle visualization throughout.

A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE

A TECHNIQUE TO PREVENT BAR DISPLACEMENT IN THE NUSS PROCEDURE Claire E. Graves, MD1, Andrew Phelps, MD1, Olajire Idowu, Jr., MD2, Sunghoon Kim, MD2, Benjamin E. Padilla, MD1. 1University of California, San Francisco Benioff Children’s Hospital, San Francisco, CA, USA, 2University of California, San Francisco Benioff Children’s Hospital, Oakland, CA, USA. Purpose: Bar displacement is a serious complication of the Nuss  procedure. Three types of displacement have  been well described: lateral sliding, bar flipping and posterior disruption. We propose a simple  modification in bar placement and  fixation that safeguards against all three  mechanisms of displacement. Methods: Nuss  bar length  is chosen to extend just beyond the pectus ridge on each side.  Using the external bar bender, we make  a gentle  curve on each side  of the bar, corresponding to the peak  of each pectus ridge.  The ends of the bar are left straight. After the bar is inserted and  flipped,  a stabilizer  is placed on each end  and  slid medially, just lateral to the chest wall insertion site. After the stabilizers are in position, in situ bar benders are used to complete the curvature of the bar around the chest wall. Results: This technique addresses all three  methods of displacement (Fig.1). Lateral sliding is prevented by locking the stabilizers in place with in situ bending just lateral to the chest exit site (A). The bar cannot move laterally as the stabilizers abut  the chest wall exit site (B). Placing  the stabilizers more  medially positions them  at the inflection point where  the ribs angle  superiorly. Thus the stabilizers straddle two ribs on the anterior chest (C). The stabilizers therefore have  a broader base of support, preventing bar flipping. Finally, placing  the stabilizers more  anterior  allows them  to directly counteract the posterior pressure on the bar from the sternum. Instead of relying on the intercostal musculature, the ribs themselves serve  to support the stabilizers and bar from posterior dislocation. Conclusion: We report  a technical modification of pectus bar placement and stabilization to minimize the risk of three  common mechanisms of displacement.

Thoracoscopic Repair of a Symptomatic Congenital Cervical Lung Herniation

THORACOSCOPIC REPAIR OF A SYMPTOMATIC CONGENITAL CERVICAL LUNG HERNIATION Stephen J. Fenton, MD, Justin H. Lee, MD. University of Utah School of Medicine, Salt Lake City, UT, USA. Purpose: Congenital cervical lung herniation is an extremely rare cause of stridor and dysphagia. It more often occurs on the right and results from the disruption of Sibson’s fascia that allows for apical lung parenchyma to herniate into the neck. There is a known association with Vitamin E deficiency, cleft lip and palate, and Cri-du chat syndrome. Surgical intervention is rarely required for spontaneous pneumothorax, stridor, dysphagia, or cosmetic issues due to the incarcerated lung tissue. Methods: We report the thoracoscopic treatment of an infant with symptomatic congenital cervical lung herniation. Results: A previously healthy 9 month-old girl was evaluated with a several week history of progressive stridor and dysphagia. The stridor was more pronounced with crying and especially noted with crawling. The parents stated that she could not crawl for prolonged distances due to increased work of breathing. She was also noted to have dysphagia and would choke while feeding unless held upright. The child appeared healthy with normal vital signs and was noted to have stridor on exam. Plain films of the neck demonstrated herniation of the right lung apex into the thoracic inlet with significant displacement of the trachea. The child underwent an elective thoracoscopic repair. An opening below the Azygous vein was identified that allowed for herniation of an apical lobe into the neck. Inflation of this trapped lobe caused displacement of the esophagus and trachea to the contralateral side resulting in her symptoms. The hernia was opened by division of the Azygous vein and Sibson’s fascia. The apical lobe was resected and the area reinforced with placement of biologic mesh. She had an unremarkable post-operative course with resolution of her dysphagia and significant improvement in her stridor allowing for normal activity. Conclusions: A thoracoscopic approach to repair symptomatic congenital cervical lung herniation is feasible.

Anterior cervical tracheoplasty using thyroid ala cartilage graft

Acquired tracheomalacia in the form of suprastomal collapse may occur as a complication of long-term tracheotomy dependence. Prolapse of the weakened suprastomal segment of trachea during inspiration may prevent safe decannulation. Management of such an issue may require a secondary surgical procedure such as anterior tracheoplasty.2 In 2001, Forte et al described the use of thyroid ala cartilage as a reliable cartilage source for anterior augmentation laryngotracheal reconstruction in neonates. This technique may yield a favorable result given similar thickness of the cartilages and use of a single incision operation for airway reconstruction.1 Here, we present a modification of the procedure described by Forte for anterior cervical tracheoplasty for the indication of suprastomal collapse preventing decannulation. The procedure begins with nasotracheal intubation and excision of tracheostomy tract and stoma. Strap muscles are then divided to expose the laryngotracheal cartilages. Cartilages are divided at the midline anteriorly, and the diseased segment of anterior trachea is discarded. The defect is measured, and if the size match is favorable, the superior thyroid alar cartilage is harvested. The resulting cartilage graft is slightly larger than the tracheal defect and is placed so that the perichondrium is facing into the airway lumen. Interrupted sutures of 4-0 vicryl are used to inset the graft in a submucosal fashion. Once the graft is secured with sutures, a Valsalva maneuver is performed after the cuff of the endotracheal tube is taken down to assure no leak. Strap muscles are reapproximated, a Penrose drain is placed, and the skin is closed. The child is kept intubated and sedated for 3 days before subsequent extubation in the intensive care unit. A bronchoscopy is performed at the 6-week postoperative interval to assure successful healing and to remove any persistent granulation tissue if present.

Adam Zanation, MD

University of North Carolina at Chapel Hill

• Director, Head and Neck Robotic Surgery Program
• Director of the Advanced Head and Neck Oncology, Skull Base, and Rhinology Fellowships
• Associate Professor, Department of Otolaryngology – Head and Neck Surgery

Dr. Adam Mikial Zanation is a tenure tract Associate Professor within the Department of Otolaryngology – Head and Neck Surgery at the University of North Carolina at Chapel Hill. He is also the Director of the Head and Neck Robotic Surgery Program and the Director of the Advanced Head and Neck Oncology, Skull Base, and Rhinology Fellowships. He was born on July 11, 1976, in Concord, North Carolina and attended the University of North Carolina where he was a three-year graduate with honors and research commendation in 1997. He then matriculated to the University of North Carolina School of Medicine where he graduated 1of 4 students in his class with highest honors. Following residency, Dr. Zanation completed a Cranial Base Surgical Oncology Fellowship at the University of Pittsburgh Medical Center. Dr. Zanation’s clinical practices focus on cranial base surgery, specifically employing endoscopic and minimally invasive approaches to complex tumor locations. His clinical research focuses on quality of life, neurofunctional, and neurocognitive outcomes, as well as application of new surgical technology such as robotic surgery to reduce patient morbidity. Dr. Zanation’s translational basic research interests focuses on genomic analyses of head and neck tumors and thyroid cancers for diagnostic and prognostic purposes. Dr. Zanation currently has 70 PubMed Indexed publications and in the last five years has presented at over 60 national and international meetings. Dr. Zanation is married to Jennifer Stegall Zanation who is a Neonatal ICU Pharmacist at UNC Hospitals. They have two young children and enjoy a multitude of outdoor activities.

Advanced Salivary Endoscopy: Challenging Cases Diagnosis & Treatment

The advanced course will assume a basic understanding of the procedure. It will include complex interventions including endoscopic and combined open (transoral and external procedures), complications and management of complications, approach to revision surgery, in-office procedures, advanced radiology, and will include case studies.

Meet the Course Directors!

Rohan R. Walvekar, MD

Assistant Professor in Head Neck Surgery

University of Pittsburgh/VA Medical Center

Rohan R. Walvekar, MD, earned his doctoral degree from the University of Mumbai. After graduating in 1998, he completed a residency in Otolaryngology and Head Neck Surgery at the TN Medical College & BYL Nair Charitable Hospital, Mumbai, India, with triple honors. Subsequently, he completed two head neck surgery fellowships, and trained at at the Tata Memorial Hospital, Mumbai, which is India's most prestigious cancer institute. After completing an Advanced Head Neck Oncologic Surgery fellowship at the University of Pittsburgh, he became an Assistant Professor in Head Neck Surgery within the Department of Otolaryngology Head Neck Surgery at the University of Pittsburgh/VA Medical Center, prior to joining the LSU Health Sciences Center in July 2008. His clinical interests are head neck surgery and salivary endoscopy. His research interests include evaluating prognostic markers and clinical outcomes of head and neck cancer therapy and treatment of salivary gland disorders.

Barry M Schaitkin, MD

Professor of Otolaryngology

UPMC Pittsburgh

Dr. Schaitkin specializes in the treatment of inflammatory and neoplastic conditions of the salivary glands. He practices at UPMC in the Department of Otolaryngology and is affiliated with UPMC branches all across the city of Pittsburgh. He completed his medical degree and residency at Pennsylvania State University College of Medicine.

Meet the Presenters!

Jolie Chang, MD

Associate Professor, Chief of Sleep Surgery and General Otolaryngology

University of California, San Francisco

Dr. Chang specializes in sleep apnea surgery and minimally invasive approaches to the salivary duct with sialendoscopy. She has interest in studying patient reported outcomes after sialendoscopy procedures.

Mark Marzouk, MD

Clinical Associate Professor of Otolaryngology - Head and Neck Surgery

SUNY Upstate Medical University

Dr. Marzouk completed his residency training in 2010 from the UPMC Department of Otolaryngology. He is currently the Division Chief of Head and Neck Oncologic Surgery in Syracuse. He is also the Associate Program Director of Residency Programs.

David W. Eisele, MD. FACS

Andelot Professor and Director - Department of Otolaryngology-Head and Neck Surgery

Johns Hopkins University School of Medicine

Dr. Eisele is the Past-President of the American Board of Otolaryngology- Head and Neck Surgery and a member of the NCCN Head and Neck Cancer Panel. He has served as a member of the Residency Review Committee for Otolaryngology, as Chair of the Advisory Council for Otolaryngology - Head and Neck Surgery for the American College of Surgeons, President of the American Head and Neck Society, and as Vice-President of the Triological Society. He served as President of the Maryland Society of Otolaryngology and is a former Governor of the American College of Surgeons.

M. Boyd Gillespie, MD, MSc, FACS

Professor and Chair

UTHSC Otolaryngology-Head and Neck Surgery

M. Boyd Gillespie is Professor and Chair of Otolaryngology-Head & Neck Surgery at University of Tennessee Health Science Center. He is a graduate of the Johns Hopkins University School of Medicine where he a completed residency and fellowship in Otolaryngology-Head & Neck Surgery. Dr. Gillespie earned a Masters in Clinical Research at the Medical University of South Carolina, and is board certified in Otolaryngology-Head and Neck Surgery and Sleep Medicine. He has published over 150 academic papers and is editor of the textbook Gland-Preserving Salivary Surgery: A Problem-Based Approach. He is a former Director of the American Board of Otolaryngology-Head & Neck Surgery (ABOHNS) and current member of the otolaryngology section of the Accreditation Council for Graduate Medical Education (ACGME).

M. Allison Ogden, MD FACS

Professor & Vice-Chair of Clinical Operations - Department of Otolaryngology

Washington University School of Medicine

Dr. Ogden is a Professor and Vice-Chair of Clinical Operations in the Department of Otolaryngology at Washington University School of Medicine. She graduated from the Washington University School of Medicine in 2002 and went on to complete her residency there as well in Otolaryngology in 2007. Her clinical interests include sialendoscopy, nasal obstructions, and hearling loss. In 2015 Dr. Ogden was listed in "Best Doctors in America", an honor that continues to this day.

Arjun S. Joshi, MD

Professor of Surgery

The George Washington University School of Medicine & Health Sciences

Arjun Joshi, MD is board-certified in Otolaryngology and Head & Neck surgery by both the American Board of Otolaryngology – Head and Neck Surgery and the Royal College of Physicians and Surgeons of Canada. Dr. Joshi received his medical degree from the State University of New York at Syracuse and completed his residency at The George Washington University Medical Center. His areas of expertise include: Head and Neck Cancer, Head and Neck Masses, Head and Neck Reconstruction, Thyroid and Parathyroid Surgery, and Salivary Endoscopy.

Henry T. Hoffman, MD

Professor of Otolaryngology / Professor of Radiation Oncology

University of Iowa Healthcare

Dr. Henry T. Hoffman is an ENT-otolaryngologist in Iowa City, Iowa and is affiliated with University of Iowa Hospitals and Clinics. He received his medical degree from University of California San Diego School of Medicine and has been in practice for more than 20 years.

David M. Cognetti, MD, FACS

Professor and Chair of Department of Otolaryngology-Head & Neck Surgery

Thomas Jefferson University

Dr. Cognetti received his BS in Biology from Georgetown University and his MD from the University of Pittsburgh School of Medicine. He completed a residency in Otolaryngology – Head and Neck Surgery at Thomas Jefferson University before completing a fellowship in Advanced Head and Neck Oncologic Surgery at the University of Pittsburgh Medical Center.  Dr. Cognetti returned to Jefferson, his professional home, as faculty in 2008.

Christopher H. Rassekh, MD, FACS

Professor in Department of Otorhinolaryngology - Head & Neck Surgery / Director of Penn Medicine Sialendoscopy Program

University of Pennsylvania

Christopher H. Rassekh, MD is Professor of Clinical Otorhinolaryngology-Head and Neck Surgery at Penn Medicine. He is the Director of the Penn Medicine Sialendoscopy Program, which provides evaluation of and minimally invasive surgery for diseases that cause swelling of the salivary glands including obstructive diseases such as salivary stones, salivary duct strictures and tumors. Dr. Rassekh sees patients with head and neck tumors including cancers of the mouth, throat, voice box, salivary gland, thyroid and neck and also was a very early adopter of Transoral Robotic Surgery (TORS) for tumors and salivary gland diseases, and is an expert in cranial base surgery. He also is co-chair of the Airway Safety Committee at the Hospital of the University of Pennsylvania.

Bilateral Vocal Cord Immobility

Future Directions for Endoscopic Ear Surgery

Drs. Joao Flavio Nogueira, Yi-Chun Carol Liu, and Arun Iyer look ahead to the future of Endoscopic Ear Surgery. They will discuss instrumentation and procedures currently in use and hypothesize where each might be headed and how it may come to be used down the road.

Cochlear Implant Surgery: Controversies and Complications

Drs. Natalie London, Kenneth Lee, Yisgav Shapira, and Sunil Dutt highlight the controversies in current Cochlear Implant (CI) guidelines, discuss common complications with CI and device selection process.

Treatment of Chronic Atelectatic Middle Ear with Endoscopic Placement of Cartilage Shield T-tube

Join this interactive webinar with Drs. Ravi N. Samy (University of Cincinnati Medical Center) James G. Naples (Beth Isreal Deaconess / Harvard Medical), and Yi-Chun Carol Liu (Baylor).

These faculty members in otology/neurotology will feature a video on the treatment of chronic atelectatic middle ear with endoscopic placement of cartilage shield T-tube while providing their commentary on the approach and sharing best practices for success.

What is Otolaryngology: More than Tonsils and Boogers

Come learn more about the jobs of Otolaryngologists (also known as ENT doctors!). We will discuss the breadth and depth of what ENT doctors cover with case descriptions. Medical students and residents of different levels will be on a panel to answer questions about the journey to and through Otolaryngology residency.

Otolaryngology Head and Neck Surgery / Resident Physician, PGY 5
Loyola University Medical Center

Dr Yang grew up in the arid and desert like climate of Eastern Washington before spending four years in rainy Seattle during her undergrad years, majoring in Neurobiology at the University of Washington. She then moved to sunny Southern California to complete her medical education at Loma Linda University School of Medicine. She is currently finishing her chief year of Otolaryngology Head and Neck Surgery residency at Loyola University Medical Center in Chicago, enjoying both life in the Windy City and surviving the cold winters. She recently matched to fellowship at Oregon Health and Science University in Facial Plastics and Reconstruction with Dr. Wax to specialize in microvascular reconstruction of complex head and neck defects. She is excited to return to the west coast and explore all the nature that Oregon has to offer.

Resident physician
University of Nebraska Medical Center

Steven is originally from San Diego, CA and attended the University of Notre Dame where he studied anthropology. He then earned a master's degree at Boston University and completed a year of service with Jesuit Volunteer Corps Northwest in Yakima, WA. Steven recently graduated from Loyola University Chicago Stritch School of Medicine and will be starting otolaryngology residency at the University of Nebraska Medical Center.

Medical Student
Loyola University Chicago Stritch School of Medicine

Alice is originally from San Jose, CA and attended UC Berkeley where she studied Molecular and Cell Biology as well as Nutrition. She is starting her fourth year at Loyola University Chicago Stritch School of Medicine, and preparing to apply for otolaryngology residency.

Resident
Loyola University Medical Center Otolaryngology Head and Neck Surgery Department

Dr. Sandelski grew up in Northwest Indiana, leaving the state for undergrad at the University of Michigan, and returning for medical school at Indiana University School of Medicine. She is in her second year at Loyola for ENT residency. She is undecided for plans after residency, with current interests in head and neck oncology and facial plastics and reconstruction.

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The Great Divide: Bringing Educational Theory To Practice In Surgical Education

This time last year I was sitting in a classroom at the school of education, learning about metacognition, reflection, and deep understanding.  It had only been 18 short years since I graduated high school and I couldn’t help but wonder – How did I get here?  I had finished my ear, nose, and throat (ENT) surgical training and quickly went from learning about resecting cancer and performing airway reconstruction to learning about teaching for understanding.

Over the previous 6 months I went from reading books from ENT legendaries like Dr. Charles Cummings and Dr. Jonas Johnson, to readings by education legendaries Edward Thorndike, Jean Piaget, Howard Gardner, and Carol Dweck.  I asked myself, what am I doing here and why do I keep pursuing more graduate education?

I realized that I was in this classroom to learn about learning and somehow parlay it into improving my own teaching, and hopefully, that of those around me.  I felt somewhat disenfranchised with the state of surgical education today.  Advances in the cognitive theory of learning were spreading like wildfire through K-12 and secondary education that, traditionally, have been missing in medical training.  As I sat there, I contemplated ways to adapt the lessons learned and bring cognitive theory to surgical education.

I preface this all with the fact that many of my instructors along my educational journey are excellent teachers, as are many people reading this post.  I also realize that everyone is a teacher and a learner everyday in their lives; whether to patients, friends, relatives, or peers, everyone teaches someone something sometime.  My goal with this post is to deconstruct our own teaching experiences and to connect them to underlying cognitive learning principles, so that we may adapt and magnify them to make ourselves more efficient and efficacious educators.

Novice-Expert Shift, Zone of Proximal Development (ZPD), and Desirable Difficulty

Theory:  The novice-expert shift is the journey our trainees take as they go from not knowing what they don’t know (true novice) to becoming experts in their field.  During this journey, they follow a path that is domain-specific and different for every student.  For example, they may develop laparoscopic skills much more swiftly than soft tissue skills, or vice versa.  The importance of this in surgical education is that no student’s growth in every domain will follow a straight line corresponding to his or her year in training.  [See Pusic et al. for more on learning curves in health professions education].  This is the principle behind competencies and milestones rapidly making their way into medical education.  Despite the recent implementation of these principles, I still hear attending surgeons say, “I never let a third year resident insert a cochlear implant or let 2^nd year residents do X”.  I still see colleagues lecturing students with the same talk they gave at conferences in years past without ascertaining where their level of understanding of their audience or leveraging their base knowledge on the subject.

The Zone of Proximal Development (ZPD) essentially lies on either side of the student growth curve and delineates the boundaries of tasks that will result in positive student learning  [See Vygotsky (1978) for more on ZPD or DiSessa (2000) on Regime of Competence].  Tasks too far below this zone are too simple and will not result in moving students much along their growth curve.  Too far above and the task is too difficult to complete, leading to learner frustration and stagnation.  The sweet spot, or what I call the Goldilocks zone, is where the student will be maximally challenged and advance furthest along their learning continuum. If you target the zone above the curve, for both cognitive and practical skills, you will maximize their growth.

Application to Practice:  In my teaching, I try to remain agnostic to residents’ training year and gauge their skill in each domain based on their own insight into their abilities, and what they demonstrate in the operating room.  Intuitively, we all probably give trainees graduated responsibilities that will stretch their capabilities.  I try to take this further and ask every individual trainee, before a case, where they are along their continuum of learning for that particular case and where they want to be after.  This requires the instructor to meet with the resident before the case or before the day starts to assess their base knowledge or skill.  Often, due to time constraints, this isn’t practical but, again, if we want to be the most efficient at teaching our residents we need to keep these concepts in mind.  During the case I give them more and more difficult tasks in a sort of game to figure out where the limit of their zone is and we stay right at that level until the case is over.  I then ask them three simple questions after each case:  “What could I have done better as an instructor?  What are areas you would like to improve on as a surgeon?  What could have everyone done better as a team?”  I try to engage the OR staff and anesthesiology team in the last question as often our cases employ the shared airway principle between our two teams.  This reflection and metacognition on our experience is another principle that we will cover another time, but is vital to their learning.  Here is where, as the expert, we can assess their insight and get a gauge of their progression on their learning continuum.

Implicit knowledge to Explicit knowledge, Context, and Schema Formation

Theory:  When I get a first-year medical student in my clinic in OR, it is extremely difficult, dare I say impossible, to imagine what it was like to be at that level.  One major barrier is that as an expert, you have highly refined and streamlined information storage in your head, and have automatized many cognitive tasks.  This organizational strategy or ‘schema’ is very individualized and content-specific.  In deciding which bookshelf to store information in your head, you have made it the most efficient for retrieval when needed and attached to other similar nuggets of information.  Along with this, as an expert, you have cleared space on the shelves by pushing out elements of information that are no longer needed because they are implicit.  You no longer need to remember that the right pedal makes the car go forward and the left one makes the car slow down.  These assumptions and automations you have introduced into practice are very difficult to unpack for the novice learner.  Imagine explaining how to drive to the grocery store to someone who has never driven a car before.  As a teacher it is very difficult to unpack every little important detail needed and make them explicit for the learner.  Master teachers are able to take their schema for a particular topic, fully deconstruct it into its component parts and transfer that knowledge in a sensible fashion to their students.

Application to Practice:  I try to imagine myself trying to learn something for the first time.  Last year I learned the basics of how to write code for websites.  I realized that a major barrier to learning anything was that you had to get the basic words that people use and understand the context in which they are used.  I had to start out by understanding what ‘h1’ meant and why it mattered.  James Paul Gee in his book What Video Games Have to Teach Us About Learning and Literacy discusses ‘situated cognition’ and ‘situated meaning.’  He explains that words are context- and domain specific and uses the term ‘work’ as an example.  This word means something totally different to human resources versus a physics professor.  We must think about the efficacy of the message if the true novice doesn’t know the words or context, especially in the context of surgery, the operating room, or even medicine.  This is the same principle we must remember when explaining surgery to our patients or families.

As I go through the surgery I try to unpack things in my own head before describing it piecemeal to the trainee.  I encourage the resident to call me out when I skip over something or they feel I made an assumption.  Residents often feel apprehensive to point out weak knowledge areas so it is essential I set up a safe learning environment.  This is also exemplified during our post procedure feedback session where we undergo a frank discussion of what went well, what needs work and how to proceed.

Cognitive Load and Chunking

Theory: Cognitive load is familiar to most.  It is essentially the mental capacity of someone to absorb information in a given learning experience.  This is traditionally split into intrinsic, extrinsic, and germane load.  These loosely can be seen as the complexity of the learning content itself, the complexity of how the content is delivered, and the mental energy needed to internalize the information.   Chunking is one technique to lower the intrinsic cognitive load by only including smaller, digestible pieces of information.  The cognitive load of any learning experience, cognitive or procedural, can be managed this way.

Application to Practice:  My attending in fellowship, David Roberson, had a great way to put this into practice.  When he taught tonsillectomy, he would do the first 90% of the surgery and then allow the trainee to finish the surgery.  The next time he would do 60% and so on until the resident was doing the whole case.  Without him knowing, he was chunking the information and managing the cognitive load so residents could focus on the task at hand.  It was also backwards design in some sense as the resident saw what the finished product looked like and could just focus on getting to the next point in the case.  They also focused on the easiest part of the case first and repeated completing the case a multitude of times instead of messing with putting the mouth gag in, initially grasping the tonsil, and finding the capsule (often the harder parts of the procedure).  When I start cases with residents I think about what they want to focus on so I can manage the cognitive load and move them along their learning curve and not dwell on things they have already mastered.

Conclusion

Over the last year and a half I have come to realize that the cognitive psychology of learning is not as scary as I had originally thought.  It underpins what many of us know as good teaching strategies.  I realize for many of us bringing theory to practice can seem overwhelming.  I found that starting with just one strategy, i.e. managing my own cognitive load, made a huge impact on my teaching.  Over time I have instituted many other cognitive principles and continue to look for ways to incorporate them into my every day teaching of students, residents, and fellows.  Which of these principles do you intend to include in your practice?   Comment on the blog to share specific strategies with our community!

Have a question you would like to ask Dr. Gantwerker? Feel free to post a comment or send him an email at Eric.Gantwerker@csurgeries.com

Csurgeries Was Live! You’ve Matched! What’s Next? With Dr. Juliana Bonilla-velez

On April 11^th, 2018 we were honoured to have Dr. Juliana Bonilla-Velez host a Facebook Live event titled ‘You’ve Matched! What’s Next?’. Dr. Bonilla-Velez is the chief resident for Otolaryngology, Head and Neck Surgery at the University of Arkansas for Medical Sciences. Originally from Colombia, she is also a founder, editorial board member and former Editor in Chief of the International Journal of Medical Students.

Dr. Bonilla-Velez shared her tips on the exciting transition from medical school to residency.  Medical students will find her discussion and step by step instructions interesting and informative as she fills in the gaps in terms of what happens next!

Topics Dr. Bonilla-Velez covers include:

• First off, celebrate, you did it!
• What to do in the months leading up to your residency
• Preparing for paperwork from your new institutions
• Moving to new cities
• Your first day of residency
• Reaching out for support, it’s okay to ask for help
• Educate yourself with survival guide like materials to know what is expected of you
• Managing clinical responsibilities
• Taking care of yourself
• Staying engaged with activities outside the clinic: Volunteering, research, academics, field organisations & associations
• Staying on top of your readings and research to continue progressing in your clinical studies
• Building leadership by getting involved in the medical community, student leadership groups, mentorships
• Setting goals over your residency
• The benefits of working with Journal Publications – IJMS. 

Key Take-Aways:

• Your colleagues have all been through it before, they can support you!
• Take your time, don’t get overwhelmed by your clinical responsibilities and make sure to take care of yourself first
• Keep and build connections in academia, the medical community and in your clinical field
• Seek leadership opportunities within your clinical field
• Set goals you can achieve over your residency.

Enabling Our Frontline Healthcare Warriors

How to Enable Our Frontline Healthcare Warriors to Use a Total Joint Hood for Total Head Protection Without the Need of a Total Joint Helmet

The Stay Strong Face Shield System was created to enable Frontline Healthcare Personnel to wear total joint hoods without needing a total joint helmet system.  Created by orthopedic surgeon, Ryan Grabow, MD, it is a resusable, face shield system specifically designed to work with total joint hoods (by Stryker and Zimmer-Biomet) and any other plastic sheeting (binder covers work great).

Through the Battle Born Maker Corps the shields are being 3D printed and donated to our frontline healthcare warriors throughout the country. All makers, hobbyists, universities, or companies with the ability to 3D print are invited to visit the website BattleBornMakerCorps.com to download the 3D printing file for free to help protect our colleagues who are on the frontlines protecting us all!

Disclosure of Conflicts:

The Stay Strong Face Shield 3D printing file is being provided free of charge to anyone wanting to download and print the face shield system to provide frontline healthcare personnel the ability to wear a total joint hood without the need for a total joint helmet that is expensive and in limited supply. Dr. Grabow holds the patent for this device.

How Surgical Videos Benefitted This Aspiring Surgeon’ By Andrew J Goates, Md

 Andrew J. Goates, MD is a first-year Otolaryngology — Head and Neck Surgery resident at Mayo Clinic in Rochester, Minnesota. He is passionate about patient and physician education through  the use of video and digital media and a member of the CSurgery Student Leaders. You can follow him on Twitter @goatesworld and on Instagram @goatolaryngologist. 

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“I like making movies, but I’m not sure what I’m going to do with it. Hopefully I’ll figure it out.”

That was my response. Those were my big career goals. It was our first date and I had just blown my opportunity to knock her socks off with my impressive aspirations and intellectual prowess. Somehow, despite her better judgement and advice of close friends, she continued allowing my romantic pursuits. Eventually, with her support, I discovered my love for medicine. We talked about my role models, many of which were in the medical field. I recognized that I wanted to do something everyday that brought new questions, challenges, and opportunities and at the same time directly impacted peoples’ lives. Medicine became the natural fit.

While in medical school and I spent the first two years trying to gain as much knowledge and experience as I could in order to match into my dream specialty of Otolaryngology– Head & Neck Surgery. I worked in the department as often as I could: helping with publications; attending lectures and grand rounds; all the while learning from residents, fellows, and staff surgeons. One of my mentors approached me about doing a surgical video on a new technique he had learned for excision of branchial cleft cysts. I didn’t know how to remove any type of cyst, and I didn’t even know what a branchial cleft cyst was. But, I did have a natural drive and curiosity, the motivation to learn, and a basic video editing skill set that I could contribute.

Through developing that video I saw the potential of surgical video footage in many aspects of education in surgery and medicine. I learned the practical anatomy relevant to this surgery. I learned about common pitfalls and picked up on the subtleties of technique and tissue handling. Although at that point I had not performed a single surgery, I got to spend a few moments in the mind of a surgeon. I became more prepared for when my opportunity to operate would soon come. In addition, I got to spend important moments learning from and working with a phenomenal surgeon. That project helped strengthen our mentoring relationship and lead to more opportunities for me to reach my potential with a strong letter of recommendation for residency applications.

Since that time I have consistently used high-quality surgical videos to research procedures, learn complex anatomy, and to augment my study of head and neck surgery. Surgical videos can help a learner assimilate difficult three-dimensional relationships and translate memorized anatomy and concepts into practical understanding needed to safely navigate a given operation. This allows a growing surgeon have a foundation on which to build the surgical skills needed to become a proficient and safe surgeon. I have really appreciated the work of CSurgeries in housing excellent surgical videos and making them available for all to benefit from.

So my career does involve making movies after all. But they are far more meaningful than what I had in mind. They don’t just tell stories. These movies teach, inspire, and motivate aspiring surgeons and inform nervous patients and their families from all over the world.

Facebook Live: Fighting Physician Burnout: 8 Practices To Train For The Inevitable Bout

On August 30^th, 2018 we were honored to have Jeff Smith, MD host a Facebook Live event. Mr. Smith is an Orthopaedic Trauma Surgeon who also assists other Surgeons to develop the critical skills needed to create a highly successful lifestyle-friendly practice which is physically, mentally and emotionally sustainable. Mr. Smith joins us to share his signature methodology “The 8 Practices of Highly Successful Surgeons” that he developed based on his own 21 years at University of California San Diego.

Mr. Smith is also a Surgeon Coach and Consultant at SurgeonsMasters, a medical education company delivering strategies and techniques overlooked and underemphasized in traditional medical training. The goal of SurgonsMasters is to focus on learning, understanding and implementing effective habits that will allow all healthcare professionals to create a thriving practice while still having time to travel, connect with family and pursue outside interests.

->Watch the video recording here<-

Mr. Smith’s Live Event covers the following topics

– The Definition and Test of Burnout

– Burnout Rates in Healthcare

– Our Perception and Awareness of Burnout

– 8 Practices of Highly Successful Surgeons

– Tips for Medical Students

– Key Take Aways

– Audience Questions & Answers

The Definition of Burnout

The Maslach Burnout Inventory (MBI)

o “Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity.”

o Find your specific MBI Test Here (https://www.mindgarden.com/117-maslach-burnout-inventory)

Burnout Rates in Healthcare

Our Healthcare culture or system is contributing to 80-90% of our burnout because of inefficiencies or stresses and frustrations imposed on us. However, there are aspects we can control with a proactive approach to train ourselves for facing burnout opposition in the ring.

– 20-30% experience burnout, but potentially more as there is less self awareness about the issue.

– High functioning organisations and departments with a physician leader who is very engaged and effective tend to have lower incidents of burnout among the physicians working under them. Ineffective leaders may be a contributing source of burnout among team members.

– Recent implementation of electronic medical records, other significant changes to the system can add stress to the environment, increasing burnout of those in the organization.

– 48% of women experience burnout vs. 38% of men. Rates increase to 50% between professionals aged 45 and 54 years old.

– Mr. Smith experienced burnout 5 years into his career and again around 50 years old. Even at those times, he was high functioning, busy and successful with his patient care as a surgeon. However, he was less efficient which is a cause of burnout.

Our Perception and Awareness of Burnout

– When surveyed, 40-60% of respondents report experiencing burnout.

– When presented with burnout statistics, we tend to hone in on our specialty in comparison to the others. But we shouldn’t care if our specialty experiences 40% vs 50% burnout when a high functioning specialty should be in the 20% range. There is a lot we can do to improve burnout rates across all specialties in healthcare.

– Burnout creates chaos and synergy. Often as physicians and healthcare administrators we help each other to win the fight. But we also tend to fight alone in our corner or even against each other, increasing stresses that lead to burnout.

– Higher rates of burnout on your team contribute to higher turnover, higher incidences of malpractice, medical errors, decreased patient safety and lost revenue.

– Our experience is not left in the clinic, hospital or research lab. It impacts other areas in our life, we take it with us which impacts our relationships, causes irritability, anxiety and in some cases mental health issues or substance abuses.

– We must take proactive steps to implement habits that reinforce a sustainable practice.

8 Practices to prevent, fight and win against burnout

1. Passion for performance

2. Reciprocity of roles & relationships

3. Attitude resilience

4. Community with mutual understanding

5. Time/life management using rhythm

6. Inspiring other to share goals

7. Complex problem solving through simplicity

8. Energy for personal & practice wellness

Tips for Medical Students

– Learn these practices early in your career, create and reinforce good habits.

– Implement these 8 practices with a regular effort

– Advance other areas other than just medical knowledge or surgery skills

– Improving communication or using simplicity to solve complex problems will help create a wider set of skills needed for a sustainable career in healthcare

– Be mindful of these practices even when you’ll intensely have to learn about one subject

– The key is being proactive and reflecting on how you did implement these practices

– Use constructive positive criticism to keep yourself engaged and accountable

Key Take-Aways

1. Reflection is Key

2. Planning & Setting Goals

3. Incremental Adjustments to Improve; “How can I do it better?”

Questions & Answer

How do we integrate others in implementing the 8 practices?

– Implementing the practices involves the Rs: Reciprocity, Roles and Relationships

– Although we can work on developing these practices on our own, in reality the 8 practices are integrated with those around you and on your team.

– Reach out to others to get feedback about your communication and time/life management.

– Ask how they perceive your quality time and how they can contribute towards improving your preventative burnout practices.

Do you have any tips for avoiding burnout during the last couple of weeks before exam?

– Start to learn healthy eating habits with a difficult schedules and odd rotations

– Start to learn sleep RECOVERY habits for those late nights studying, on rotations, and so on

– Find a way to get regular exercise, even if not your ideal form or quantity. Learning how to do it anyways is really helpful for the future

– Take the opportunity to reflect on what you’re doing. Over a series of exams, review the strategies you found effective and repeat them, making incremental adjustments to keep that success going.

– Allow a small physical recharge, a mental recharge or rest by taking mini breaks.

– Have the ability to support your connections, address people and stay positive!

The People Behind CSurgeries: Gresham Richter MD, FACS, FAAP

Meet Gresham Richter ─ Professor, Academic Surgeon and Co-founder of CSurgeries
(Better known as “G” to his colleagues at CSurgeries).

Q: How did CSurgeries get started? How did you come up with idea?

A: CSurgeries was originally developed to be an educational surgical outlet that was video based- to teach trainees how to perform the surgeries or  at least ask the appropriate questions during the procedure.  It was going to be a CD-based system, but then we realized we wanted to expand the market, not just for residents, but for everyone…students, patients and other surgeons alike.  We wanted to capture details for every field and do it on a grand scale, applicable to a bigger audience.

With this goal in mind, CSurgeries became a web-based venue.  To encourage publication, we wanted to make this a win-win for the surgeons taking the time to produce the video. Our answer was simple. Our “aha” moment, so to speak was… the videos submitted by our colleagues must be a peer reviewed publication where credit is given and the videos are validated.

Q: What can you tell me about CSurgeries that’s not on the website?

A: It’s an amazing site! It’s the perfect opportunity for surgical educators and anyone else trying to learn about a particular surgery or technique.  Surgical leaders from around the world are involved. There is so much activity already happening on CSurgeries.com.  Patients, students, and expert surgeons are exploring the posted peer-reviewed cases.

Q: What makes CSurgeries unique?

A: We are unique in so many ways, but really it’s the people behind CSurgeries team that make us unique. We are an academic physician owned and operated organization. Our mission as is to teach and we understand how to value video content for publication. We have brought in education leaders in each specialty who are hands-on ─ participating, editing, and overseeing the videos produced and published on the site. It has become clear also that those submitting are interested in authoring videos to teach, not just to have something on the internet.
We understand that in the area of academic surgery, publication is critical. We allow surgeons, and their trainees, to get academic credit for their high quality and annotated videos of procedures; each of our videos is peer –reviewed and as a result we are being recognized as the premier site for validating their procedures with a publication. In fact, each video that gets approved get assigned its own DOI publication number.  Companies like Research Gate already recognize our videos as a publication. Soon we head for PubMed and other Medline search engines…

Q: You are a surgeon. You are a teacher. You are an entrepreneur. Do you sleep?

Just enough. I have a very regimented schedule between family and work. Up early, home for dinner, kids to bed by 8pm and then I get right to work. Consistency helps. Family is critical. Thus sometimes I’m late to our late team conference calls!

Q: What advice would you give a medical student thinking about becoming a surgeon?

It’s a wonderful world and life…very rewarding.  More importantly, learn as much as you can by observing and operating as much as possible.

Q: What would you be doing, career-wise, if you didn’t become surgeon?

I actually went to med school to become a psychiatrist but I realized that I was simply not patient enough. Honestly, I think I would be in the business world one way or another. Fortunately, now I have a mix of both. Like they say they in Arkansas, sometimes a blind squirrel finds a nut.

Q: Where do you see surgical education headed…let’s say in the next 10-15 years?

Streaming education and no more books. On-line interactive education with video and chat. In this sense, surgical education is going to follow internet advances.

Have a question you would like to ask Dr. Richter? Feel free to post a comment or send him an email at gresham.richter@csurgeries.com

The People Behind CSurgeries: Dr. Gerald Healy, CSurgeries Chief Surgical Officer

Meet Dr. Gerald Healy –
accomplished otolaryngologist and dedicated family man.
Learn more about his recipe for success and
how all surgeons can benefit from what he calls a
“House of Surgery”.

Q: What can you tell me about your role as Chief Surgical Officer, of CSurgeries? What are your main areas of focus?

A: First and foremost this really is a unique opportunity! There isn’t any other publication vehicle where all of the “House of Surgery” (as I like to call the surgical groups that are represented on CSurgeries) can present a compendium of information acceptable to all surgeons of all disciplines. As a specialty surgeon, I feel strongly that the surgical disciplines do not interact enough with each other. We have developed a silo mentality in medicine where we’re so focused on our own discipline, we fail to learn from the others. With CSurgeries, we have the ability to learn from surgeons in other disciplines. Even during my tenure as president of the American College of Surgeons, I worked to promote this “House of Surgery” concept ─a place where everyone lives and works together for the common goals of patient safety and quality care.

My primary role as Chief Surgical Officer, is to recruit the very best people we can find in the various surgical disciplines to be the Section Editors. We’ve welcomed some very well-known, accomplished surgeons (such as Dr. Britt who is our General Surgery editor and Dr. Shamberger who is our Pediatric Surgical Section Editor). The idea is to reach out to surgical leaders like these who can then go out and recruit the best videos. Our Section Editors are extremely well respected, recognizable names in their field. So much so that when they pick up the phone, you listen to what they have to say. People recognize that these individuals would only be affiliated with a valid journal that has something worthwhile to offer.

Q: What does CSurgeries have to offer learners of every type (trainees, patients, families, experienced surgeons) compared to other channels of surgical education?

A: CSurgeries is dedicated to serving all of those groups, and we will have to pay special attention to the development of a video library/process that addresses every viewer group. For example, the video presented to a lay person about a laparoscopic cholecystectomy might be completely different from the video we show an advanced surgeon who wants to simply see, “How does Dr. X take out gall bladder? I’d like to see the little tricks he uses when he’s in there”. Paying close attention to the viewing audience is critically important as we move forward- ensuring the production of educationally appropriate videos geared towards each viewer group or learner group.

Similarly, if we’re addressing a medical student audience, it would be acceptable to show them the same video of the gall bladder removal that we might also show a senior surgical professor. However, the audio portion (author explanation/narration) might be very different. Simply stated, the senior professor doesn’t need me telling him, “Put the scope here and look 30 degrees there”. He or she already knows that. What they want to know is, “What kind of a clamp does Dr. X use?” or “What kind of a clip, does he put on the gall bladder when he’s finished?” I expect those nuances would be differentiated through the video narration itself.

Q: Dr. Healy, your list of accomplishments are endless…You are an author, lecturer, scholar, and honorary society member (just to name a few). Where do find this motivation, what fuels you?

A: Like many people in many walks of life, I had a role model that I wanted to emulate. The short version is that when I was a small kid, I have this memory of my pediatrician who would come out in the middle of the night, in the snow, in the rain, and in the ice to see me because I was sick. Those visions stayed with me for my early life and drove me with a passion. I wanted to be like this guy. His name was Eli Friedman – an incredibly unique human being who actually has a lectureship at Boston Medical Center named in his honor because so many of his students over the years were so adoring of him. He’s what drove me.

I always knew I wanted to become a physician, but the question was whether or not I could achieve it. Could I get there? And once I got there, what was I going to do with it? The driving force behind my career really unfolded in three phases:

1. The first third of my career, I was a learner. I tried to absorb everything I could from everyone I met because I wanted to be the best surgeon I could be-helping patients with the very best of my ability.
2. The second part of my career, I made a concerted effort to try and share my experiences with others. I spent a lot of time giving talks, writing papers, presenting my material at various meetings and listening to the critiques.
3. The final third of my career, I decided to help as many as I could by becoming involved in medical organizations focused on driving the agenda so that we were always focused on what’s best for the patient and their quality of care.

*I’m also a passionate guy, who loves his family, always makes time for my wife and daughters and am driven to do the very best I can in all things.

Q: What advice would you give a medical student thinking about becoming a surgeon?

A: First and foremost, DO NOT look at medicine as a job. It’s a profession. Too many students today are looking at lifestyle choices. Being a surgeon is not an easy lifestyle. So, if you’re about working 8 am to 4pm and having all your nights and weekends off, don’t become a surgeon. But if you’re passionate about helping others, easing suffering, and changing things for the better, there is no part of our profession that’s more rewarding than surgery.

I often address medical students in and around Boston, and I let them know they are being given a unique privilege- the privilege of holding the life of another human being in their hands. It is an immense responsibility that you cannot take lightly. Once that person puts their trust in you and says, “Doctor, I need your help…” they need your help until the problem is solved. It’s not a job. It’s a profession and a calling.

1. How has medical teaching and surgical learning evolved over the years? Where do you see it going years from now?

Well, when I went to medical school, everything was pictures, book and journal reading and so forth. Now the electronic world has taken over. Visual learning, e-learning and interactive learning is the new norm. When it comes to surgery, people want to talk less and see more. That’ simply the world we live in. Today, simulation and the use of simulators is also extremely important.

I believe we are going to be heavily into robotic surgery. That’s a very important issue to think about because surgeons can easily make the mistake of becoming technicians and not doctors. By that I mean, operating, but having no relationship with the patient. Robots will replace you in the future if you enter surgery solely focused on being a technician and not an empathizing doctor. Let’s not forget about the importance of positive doctor-patient relationships…the very human side of surgery.

Have a question you would like to ask Dr. Healy? Feel free to post a comment or send him an email at Gerald.Healy@csurgeries.com

CSurgeries: An International Perspective With Dr. Juliana Bonilla-Velez

Dr. Juliana Bonilla-Velez

PGY 4 – Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences
​

Tell me a little bit about yourself.

My name is Juliana Bonilla-Velez, and I’m a 4th year resident at the University of Arkansas for Medical Sciences. I’m originally from Colombia, and that’s where I did my medical training. I was very fortunate to work with Dr. Rocco at Mass Eye & Ear Institute as a postdoctoral research fellow on oropharyngeal cancer, and then I came to do my residency training at UAMS. Here, I was also very fortunate to be able to work with Dr. Richter – who is not only one of the founders but an avid promoter of CSurgeries.

He introduced me to CSurgeries very early on in my training. It really is an amazing tool, especially for residents to be able to easily visualize all the things that you are reading!  At times, it can be difficult to put all the aspects of a surgery together (especially if you haven’t seen that type of surgery before) or to learn how different people [surgeons] do things. There are so many different techniques for each type of surgery, so I feel like it’s a great avenue that enriches resident education.

Dr. Bonilla-Velez, I understand you published with CSurgeries in June 2016.  What can you tell me about your experience? Was it easy? Difficult?

It was my first experience making a video, so that was a little challenging. I was working together with a medical student and we made a really good team.  She worked a bit more on the media aspect of helping to put the video together, but then we were able to work together and incorporate some of the more technical aspects of the surgery, and important steps and findings to highlight.

In fact, the recording of the procedure was not difficult at all. It did not interfere with the clinical aspect of what we were doing. The surgery went great, and recording did not obstruct it, make it slower or impose any impediment to the completion of the surgery. At the same time, it was very insightful to be able to review all of it and to put it together in a format that would be easy to teach others what was going on. Not only was it a great experience…it was fun!

It’s very interesting that as a resident you were able to partner with a medical student to take over the technical aspect of video recording and editing while you were able to oversee and supervise the surgical content. Having recently partnered with the International Association of Student Surgical Societies, it confirms that we’re going in the right direction. 

Absolutely. Even as a medical student, I was very involved in research and publication. I was actually one of the founders of the International Journal of Medical Students which was an amazing experience, but also gave me a better understanding of the other side of making science. From a medical student’s perspective, it is such an enriching and fulfilling experience to be able to participate in all of these avenues for publishing – participate in research projects, writing manuscripts or making videos – just learning how to think in that way, getting your feet wet and learning all of these skills are so important for the rest of your career as a physician, especially now with evidence-based medicine.

How has publishing with CSurgeries contributed to education as a surgical resident?

As an author, it was very interesting to be able to go through the process of putting the video together, thinking through all the technical aspects of what we were doing and summarizing it in a short format that would be easy to show others.

As a viewer and user of CSurgeries, it allows you to be able to see different techniques for different types of surgeries. Perhaps the Attending at your institution is doing the procedure one way, but seeing how others are doing it in other places certainly enriches your education. In preparation for surgery, CSurgeries publications allow you to see what the steps are, so you can get a more visual understanding of what it is you are going to be doing and what you’re reading in the books. In surgery, even more so than other specialties, this is critical. Learning in 2D in one thing.  Being able to see in 3D what it is you’re actually going to be seeing in surgery is quite another. For that reason, CSurgeries is definitely a very valuable tool – especially for people in training.

As a user of CSurgeries, is there a particular CSurgeries publication you recommend (either within or outside of your specialty) you recommend for our members to view and why?

As a 4th year resident, at least in my program, we haven’t started our otology rotation, so I feel like I struggle a little bit more trying to imagine and put together all the otologic surgeries. I haven’t been exposed to them nor have I seen them before. For that reason, one video that was very useful to me that I really enjoyed was Right Stapedotomy that was published by Dr. Babu at the Michigan Ear Institute. Just seeing the video, especially with the ear (it’s such intricate anatomy) was extremely useful. Having access to such a high-quality video that walks you through the surgery, seeing all the steps clearly, was really great.

Of course, there are going to be personal circumstances for which you would find a video more educational than others- depending on what your institution does or your prior experiences. One of the really neat things about CSurgeries is that there’s so much variety- not only within otolaryngology, but among all the other specialties. It’s got something for everyone.

You mentioned you are also a founder of the International Journal of Medical Students. What can you tell me about the IJMS?

Our vision was to create a space that would be made by medical students for medical students to promote research and to provide an avenue for publication that would include all specialties. We aim to speak to medical students who are in a unique part of their training. Not only do we offer a window for them to show their publications, but we are able to help get them to that high-quality level of having a paper that is amenable for publication.

It was also a very exciting to build a team of people that would be able to represent all  – not only from around the globe but also those in different stages of their training. We have mentors who have guided us from the beginning, taught us to put all these pieces together and to provide not only an avenue but a service for medical students worldwide where they can publish their work and learn. Especially nowadays where medicine is guided by the paradigm of Evidence-Based Medicine, it’s critical for physicians to be able not only to do research but to understand the research that is published. It serves to train both the authors and the students who are learning to be the editors about all the different aspects of the publication process.  It’s been a really very rewarding experience knowing we’ve been able to contribute to medical students’ education worldwide.

How is publishing with CSurgeries different from publishing with IJMS? How are they similar?

It’s different in the sense that the CSurgeries is a video peer-reviewed journal. It’s very visually perfect for the surgical field because it takes you through the novel of each surgery by  showing what the key structures are and the key steps you need to be doing. It’s very educational, especially for people in training. In terms of similarities, both aim to educate physicians, students and other surgeons. IJMS provides an avenue for written publication of research along with the more traditional strategies while CSurgeries provides an avenue for video publication. Both share a common mission of education.

What advice do you have for international medical graduates looking to pursue surgical residency in the United States?

It’s certainly a very difficult task, but at the same time, it can be immensely rewarding. You have to be very passionate about what you want to do, what you want to accomplish, and what you want for your life. If your goals are clear and you can translate all that passion into hard work and dedication to your specialty, that goes a long way. It’s certainly hard but not impossible. I’d highly encourage you to push through the difficulties if you feel that’s your life mission. Don’t give up on your dreams.

What would you be doing if you were not a surgeon?

Oh gosh! There is nothing else I would rather be doing! I wish I could have a parallel life to be able to do all the things I want to do, but all at the same time. But certainly the life I would not give up is being a future pediatric otolaryngologist and be able to continue to participate in academics, in research and education, and in clinical practice and leadership.  I look forward to playing a part in furthering the field

Watch Dr. Juliana Bonilla-Velez’s video Excision of Thyroglossal Duct Cyst and her Facebook Live, You’ve Matched, What’s Next?

Facebook Live: There Are No Do-Overs In Surgery, Capture It Right The First Time

On May 30th, 2018 we were honoured to have Rachel Simon-Lee host a Facebook Live event. Rachel is the founder and lead editor of Heartwork Videos. Rachel joined the Media Services team at BJC HealthCare in 2011 and quickly became the only dedicated surgical video producer in the organization. Her work on over 200 case edits inspired her to start Heartwork Videos.

Rachel shared her expertise and best practices for creating high quality surgical videos. Surgeons, Clinicians and Medical Professionals will find her step-by-step guide to be the perfect place to start or improve on capturing surgical footage for educational videos.

->Watch the video recording here<-

Topics Rachel Simon-Lee covers include:

• A trusted partner, not a headache. Surgical videos can:
  • Help you understand your performance by capturing mistakes and errors. Function as a quality control mechanism by facilitating objective analysis.
  • Provide new opportunities for case-based learning to clinicians, medical students and medical professionals.
  • Help with your deliberate practice by identifying and analyzing errors, becoming aware, and breaking the chain of events that eliminates adverse outcomes.
• Be proactive, engage stakeholders
  • Find individuals that will help you take advantage of new technology and new opportunities; embracing change.
  • Communicate benefits clearly, you can never over-communicate!
  • Address concerns that patient safety will not be impacted by these changes.
  • Ask for input from stakeholders. Gather feedback on what makes it easier for them.
• How to make a quality video: Focus, framing & audio
  • Focus on what you are trying to show the audience, check the camera angle. Do you have the right equipment to capture everything you need during the surgery?
  • Framing: Can you see what you want to show your audience, check the lighting for brightness and things that may impact your lighting: Retractors, towels, battery life of the camera, the light color, and other lights in the room.
  • Audio: Check for background noise, correct pronunciation and pitch. Ask yourself “Do we need live audio? If the surgeon doesn’t usually speak during the procedure, will it be distracting?”. Find a good narrating pace with your audience in mind.
  • Post production: Add annotations or sub-titles on the video to further convey important parts of the video. You can also find a quiet place to record just the narration of the video for higher audio quality.
  • Do a test-run of the set.
  • Remember to “Tell A Story” with the video.
• Cameras: Your best options for high quality videos
  • Option 1: BFW Pharos Camera – CoAX –light and camera are a 2-in-1
  • Option 2:  Loupecam: HD Camera that installs on loupes or headlight
  • Option 3: DSLR Camera on a tripod
• Test, compare & fall in love
  • Best-case scenario: A non-intrusive high quality video.
  • Be prepared to troubleshoot the equipment for multiple scenarios – different types of operations and team members.
  • Ensure the entire operating team is comfortable – especially the surgeon.
  • Take notes on what you like, and why!
• Sustainability
  • Be intentional in your video recordings: How many videos do you want to record each week? Can you sustain this going forward?
  • Consider bringing in an on-call videography team
  • Make sure your team is still committed to making these videos. Make sure they feel supported, engaged and cross-trained on the equipment in case of leave for vacations.
  • Where is the footage going? One video a week can result in a lot of data and time needed to edit for presentations or clips for journals.
• Post-Production
  • Produce and publish.
  • Think of your available publishing platforms.
  • Editing surgical videos require a lot of time, so look for an editor that has prior experience with surgical videos and knows what to look for.
• You need to figure out what works best for you and your team.
  This will require the initial installation, some tweaking, troubleshooting, and really working to get it right.

Key Take-Aways

• Who is on your team?
  • Who is working with you on this new project?
• What can you sustain?
  • Film what you and your team can commit to and sustain.
• What’s the value of a professional surgical video editor?

Also in the Facebook Live Q&A

• Learn how much it costs to hire a good video editor, how much editing to expect on a video production, and the expected turnaround time for Rachel and her team at Heartwork Videos.

->Watch the video recording here<-

Heartwork Videos partners with CSurgeries on creating high-quality surgical videos.

You can reach out to Rachel Simon-Lee at:

Telephone: 615-289-8819
Email: Rachel@heartworkvideos.com
Twitter: @heartworkvideos ‏
Facebook: www.facebook.com/heartworkvideos
LinkedIn: https://ca.linkedin.com/company/heartwork-videos

Additional questions:

Question: A good editor typically costs $100/hour, and a little more for surgical videos because it’s a unique specialty. For every hour of video, there is usually a factor of 1.5 to 2 hours for editing behind the scenes. Typically, more experienced surgical video editors won’t take as long compared to beginner editors or editors who are unfamiliar with surgeries.

Question: Turn around time: 20 days or less, but usually around 10 to 14 days contingent on the communication (back and forth for feedback) with surgeons letting us know what they like and don’t like in the video.

Question: Does it take a long time to implement new technology in the operating room? It will take at least 3 months to get things comfortable with everyone in the operating room.

Surgical videos can do so much good for the world, but require some time and resources to prepare. For Rachel, it’s truly a labour of love. You can reach out with your ideas to Rachel@heartworkvideos.com to get started.

Meet our Presenters for Day 1!

The International Adult Airway Symposium is coming up on February 4th & 5th. For more information view the itinerary or register here!

Dr Gitta Madani, FRCR, MRCS, MBBS, FDSRCS, BDS

Consultant Radiologist and Honorary Senior Lecturer

Imperial College Healthcare NHS Trust and Imperial College London

Gitta Madani is a Consultant Radiologist with a specialist interest in all aspects of head and neck and skull base radiology and performs image-guided procedures in the head and neck. She is an Honorary Lecturer at Imperial College London and involved in research, training and teaching. She has authored several book chapters, various peer-reviewed articles and national imaging guidelines.

Ali Zul Jiwani, MD, MSc, DAABIP

Director of Interventional Pulmonology

Orlando Health Cancer Institute

Dr. Jiwani, is a board-certified interventional pulmonologist with the Rod Taylor Thoracic Care Center at Orlando Health Cancer Institute where he also leads the institute’s lung cancer screening program. As an interventional pulmonologist he specializes in minimally invasive diagnostic and therapeutic endoscopy and other procedures to treat malignant and benign conditions of the airway, lungs and thorax plus pleural diseases.

David E. Rosow, MD, FACS

Director, Division of Laryngology and Voice / Associate Professor, Dept. of Otolaryngology

University of Miami Miller School of Medicine

Dr. Rosow is Associate Professor of Otolaryngology at the University of Miami Miller School of Medicine, where he has led the Division of Laryngology and Voice for over 10 years. His research and clinical interests include laryngeal cancer, recurrent respiratory papillomatosis, vocal fold paralysis, laryngotracheal stenosis and airway reconstruction, and spasmodic dysphonia. In addition to scientific publications in these areas, he has also written and edited a textbook on evidence-based practice in Laryngology.

Professor Stephen R Durham MD FRCP

Professor of Allergy and Respiratory Medicinec

National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital London

Professor Durham is Head of Allergy and Clinical Immunology at NHLI and has run a joint Nose Clinic with Professor Hesham Saleh for many years. His research interests include allergic rhinitis, asthma and translational studies in allergen immunotherapy. He is a member of the Steering Committee, Immune Tolerance Network, National Institutes of Allergy and Infectious Diseases, NIH, USA.

Professor Jane Setterfield

Professor of Oral & Dermatological Medicine

Guy's & St Thomas Hospital & King's College London

Jane Setterfield is Professor of Oral and Dermatological Medicine at King’s College London and Consultant in Dermatology at St John’s Institute of Dermatology, Guy’s & St Thomas Hospitals. She leads the Oral Dermatology Service both at St John’s Institute and the Department Oral Medicine Guy’s Dental Institute. Her areas of clinical interest include immunobullous diseases, lichenoid disorders vulval dermatoses and mucocutaneous diseases. Her research areas include diagnostic techniques, pathogenic mechanisms, clinical outcome measures and optimising therapeutic approaches for mucocutaneous diseases.

Laura Matrka, MD

Associate Professor

Ohio State University Wexner Medical Center Department of Otolaryngology - Head and Neck Surgery

Laura Matrka, MD, is an Associate Professor at the Ohio State University Wexner Medical Department of Otolaryngology – Head & Neck Surgery. She graduated magna cum laude from Dartmouth College with a BA in English and concentrations in Anthropology and Spanish, completed medical school at University of Cincinnati College of Medicine, completed her residency in Otolaryngology at The Ohio State University, and completed a Laryngology fellowship at the University of Texas Health Sciences Center, San Antonio. She is a full-time clinician who devotes significant additional time to clinical research, focusing on complicated airway management, tracheostomy complications, dysphagia after anterior cervical spine surgery, recurrent respiratory papillomatosis, gender-affirming health care, and opioid-related research, among other topics. She was inducted into the American Laryngologic Association in 2020, the Triological Society in 2019, and the American Bronchoesophageal Association in 2015.

Alexander Gelbard, MD

Co-Director

Vanderbilt Center for Complex Airway Reconstruction (AeroVU)

Dr. Gelbard is a board certified Otolaryngologist at Vanderbilt University in Nashville Tennessee specializing in adult laryngeal and tracheal disease. He completed his undergraduate education at Stanford University, medical school at Tulane School of Medicine, and internship and residency at the Baylor College of Medicine in Houston Texas. Dr. Gelbard completed a postdoctoral research fellowship in Immunology at the MD Anderson Cancer Center as well as a clinical fellowship in Laryngeal Surgery at Vanderbilt School of Medicine. He has authored numerous peer-reviewed articles and book chapters and lectures internationally on adult airway disease. He currently is Co-director of the Vanderbilt Center for Complex Airway Reconstruction (AeroVU). Additionally, he is a NIH-funded principle investigator studying the immunologic mechanisms underlying benign laryngeal and tracheal disease. He is also PI of an externally funded prospective multi-institutional study of idiopathic subglottic stenosis (iSGS) and managing director of the North American Airway Collaborative (NoAAC). NoAAC is a funded, multi-institutional consortium with 40 participating centers in the United States and Europe that works to exchange information concerning the treatment of adult airway disease. It is composed of outstanding collaborators who pursue a unique combination of genetic, molecular, and epidemiologic based approaches to investigate the critical factors underlying the pathogenesis and outcomes of laryngotracheal stenosis.

Taner Yilmaz, MD

Professor of Otolaryngology-Head & Neck Surgery

Hacettepe University Faculty of Medicine, Ankara, Turkey

Dr. Yilmaz has worked in laryngology since 2000. He is a member of ELS, ALA and IAP, publishing 94 international manuscripts which received 1100 citations. On top of those achieveiments, he also has two patents for a laryngoscope for arytenoidectomies and an epiglottis holding forceps for grasping a floppy epiglottis that folds inside the larynx during larygoscopy.

Edward J. Damrose, MD, FACS

Professor of Otolaryngology-Head & Neck Surgery

Stanford University School of Medicine

Dr. Damrose is Professor of Otolaryngology/Head and Neck Surgery and (by courtesy) of Anesthesiology, Perioperative & Pain Medicine in the Stanford University School of Medicine. He is the founding Chief of the Division of Laryngology and Program Director of the Stanford Fellowship in Laryngology & Laryngeal Surgery. He is member of the American Laryngological Association as well as the Triological Society, and has authored or coauthored more than 80 peer reviewed publications and 16 book chapters.

Kate Heathcote, MBBS, FRCS

Consultant Laryngologist

University Hospitals Dorset

Kate Heathcote established the Robert White Centre for Airway, Voice and Swallow to provide a comprehensive diagnostic and treatment service. She has lectured and trained surgeons nationally and internationally in cutting edge laryngology techniques.

Phillip Song, MD

Division Director in Laryngology

Imperial College LonMassachusetts Eye and Ear Infirmary

Dr Song is the Division Director of Laryngology at Massachusetts Eye and Ear Infirmary and Assistant Professor of Otolaryngology and Head and Neck Surgery at Harvard Medical School. He specializes in laryngology with a special interest in neurolaryngology and central airway disease.

Brianna Crawley, MD

Associate Professor, Co-Director

Loma Linda University Voice and Swallowing Center

Dr. Crawley is a board-certified otolaryngologist and member of the Academy of Otolaryngology- Head and Neck Surgery, the ABEA, and the post-grad ALA. Her interests include neurolaryngology, swallowing disorders, performing voice and the surgical airway. She continues to work in new fields of research focusing on presbylarynx and presbyphonia, neurolaryngology, and understanding the patient experience.

Ramon Franco Jr, MD

Medical Director, Voice and Speech Lab, Senior Laryngologist

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston MA, USA

Dr. Ramon Franco is a board-certified laryngologist who specializes in voice, swallowing, and breathing disorders. His main areas of expertise are in the diagnosis and treatment of voice disorders, airway stenosis, laryngeal cancer, and neurological disorders affecting the voice box. He also has special interests in the medical and surgical care of the professional voice. He serves as an Executive Board Member for the Massachusetts Society of Otolaryngology and is a fellow for the Triological Society and the American Laryngological Association.

Clark A. Rosen, MD

Co-Director / Chief - Division of Laryngology

UCSF Voice and Swallowing Center

Clark Rosen, MD is a Co-Director of the UCSF Voice and Swallowing Center, Chief of the Division of Laryngology, Professor of Otolaryngology-Head and Neck Surgery and the F Lewis Morrison MD Endowed chair of Laryngology. Dr. Rosen inaugurated modern laryngology at the University of Pittsburgh beginning in 1995 creating a dedicated center of excellence in Laryngology: University of Pittsburgh Voice Center. Dr. Rosen originated the outstanding Fellowship in Laryngology and Care of the Professional Voice at the University of Pittsburgh in 2002 and trained over 15 fellows in Larynogology and numerous visiting Otolaryngologists until 2018. He is now the director of the Laryngology fellowship at the UCSF Voice and Swallowing Center. Dr. Rosen has been a sought after speaker internationally and has had major service to multiple publications and professional societies. He is a founding member of the Fall Voice Conference, was the Vice Chair of the Annual Meeting Program Committee for the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), and was the Treasurer of the American Laryngological Association (ALA) and is now president of the ALA.

Meet our Presenters for Day 2!

The International Adult Airway Symposium is coming up this weekend! For more information view the itinerary or register here!

Dr. Vyvy Young

Associate Professor and the Associate Residency Program Director in the Department of Otolaryngology-Head and Neck Surgery

University of California – San Francisco

VyVy Young, MD, is an Associate Professor and the Associate Residency Program Director in the Department of Otolaryngology-Head and Neck Surgery at the University of California – San Francisco. Dr. Young received her undergraduate and medical degrees from the University of Louisville, in Louisville, Kentucky, where she also pursued her Otolaryngology training. She then completed a fellowship in Laryngology and Care of the Professional Voice at the University of Pittsburgh Voice Center. She currently serves the American Academy of Otolaryngology – Head and Neck Surgery as member of the Annual Meeting Program Committee and Executive Committee for ENThealth.org. She is immediate past-chair of the Voice Committee and the Women in Otolaryngology Communications Committee and was recently selected as chair of the Finance and Audit Committee of the American Broncho-Esophagological Association.

Justin Roe, PhD, FRCSLT

Clinical Service Lead - Speech and Language Therapy – National Centre for Airway Reconstruction

Imperial College Healthcare NHS Trust

Dr. Roe is a clinical-academic and service lead, specialising in dysphagia in benign and malignant head and neck disease. He leads the speech and language therapy service for the National Centre for Airway Reconstruction at Imperial College Healthcare NHS Trust and is a consultant and service lead at the Royal Marsden NHS Foundation Trust. He is an Honorary Clinical Senior Lecturer at Imperial College London and an investigator on a number of NIHR portfolio studies. He is currently on an NIHR Imperial Biomedical Research Centre/ Imperial Health Charity funded post-doctoral research fellowship. He is an elected council member for the British Laryngological Association and British Association of Head and Neck Oncologists.

Professor Anil Patel MBBS PhD FRCA

Clinical Anaesthetist / Chairman of Department of Anaesthesia

Royal National ENT & Eastman Dental Hospital

Professor Anil Patel graduated from University College London in 1991. He is a clinical anaesthetist and continues to develop and refine the largest experience of anaesthetising adult airway patients under general anaesthesia (> 6,000 procedures) in the UK, probably Europe and possibly the world. His research interests include all aspects of shared airway and difficult airway management. Professor Patel has been an invited speaker to over 300 national and international meetings in 38 countries. He has over 130+ peer reviewed publications, 25 book chapters, over 4,500 citations and an h-index of 25.

Robbi A. Kupfer, MD

Associate Professor, Department of Otolaryngology-Head & Neck Surgery

University of Michigan

Dr. Kupfer is an Associate Professor of Otolaryngology-Head & Neck Surgery at the University of Michigan who specializes in Laryngology and Bronchoesophagology. She is the Program Director for the Laryngology Fellowship as well as the Otolaryngology Residency at the University of Michigan.

Alexander T. Hillel, MD, FACS

Associate Professor

Johns Hopkins University School of Medicine

Dr. Alexander Hillel is a Laryngologist, Residency Program Director, and Vice Director of Education in the Johns Hopkins Department of Otolaryngology – Head & Neck Surgery. His clinical practice and research centers on the treatment, prevention, and causes of laryngotracheal stenosis (LTS).

Dale Ekbom, MD

Associate Professor of Otolaryngology / Director of Voice Disorders/Laryngology

Mayo Clinic

Residency in Otolaryngology/Head and Neck Surgery at the University of Michigan with a fellowship in Laryngology/Care of the Professional Voice at Vanderbilt University Medical Center. Clinically specializing in voice, especially management of vocal fold paralysis, Zenker’s diverticulum and Cricopharyngeal muscle dysfunction, early laryngeal cancer, and airway compromise due to laryngeal, subglottic, and tracheal stenosis. Research interests include idiopathic subglottic stenosis and GPA with surgical and medical management of the airway, vocal fold paralysis, new injectables using Jellyfish collagen.

Dr. Ricky Thakrar

Consultant Chest Physician

University College London Hospital

Dr. Ricky Thakrar qualified in Medicine from Imperial College London. He trained in Respiratory Medicine at the Royal Brompton Hospital and completed his training in Northwest London. He was appointed to a three-year academic fellowship at UCL where his PhD examined state of the art bronchoscopy techniques for managing cancers arising in central airways and lung. He is a Consultant in Thoracic Medicine and his main interests are in interventional bronchoscopy procedures (laser resection, airway stenting, cryotherapy, photodynamic therapy and brachytherapy) for pre-malignant and malignant disease of the tracheobronchial tree.

Dr. Michael Rutter

Director of the Aerodigestive Center

Cincinnati Children's Hospital

Dr. Rutter is an ENT surgeon specializing in pediatric otolaryngology with an emphasis on airway problems in children, adolescents and young adults. His interests include tracheal reconstruction and complex airway surgery. Always a problem-solver, he strives to involve the patient in their own care by having them help evaluate the issue and then craft a solution together. He was drawn to his career by the challenge and highly individualized nature of pediatric airway problems and management. Dr. Rutter enjoys working in a multidisciplinary team setting and focusing on coordinated care for complex childhood airway conditions. He was honored to receive the 2016 Gabriel Frederick Tucker Award from the American Laryngological Association, and the 2018 Sylvan Stool Teaching Award from the Society for Ear Nose and Throat Advancement in Children (SENTAC). These awards are for his contributions to the field of pediatric laryngology. In addition to caring for patients, he is also dedicated to his research trying to find improvements in airway management.

Christopher T. Wootten, MD, MMHC

Director, Pediatric Otolaryngology—Head and Neck Surgery

Vanderbilt University Medical Center

Dr. Wootten has a longstanding interest in surgical management of congenital and acquired airway disorders.  To better equip himself to lead the Pediatric ENT service through expansion, evolution of practice models, and differentiation into multidisciplinary care, Dr. Wootten obtained a Masters of Management in Health Care at Vanderbilt’s Owen School of Business in 2017.  Areas of his professional research emphasis include airway obstruction in children and adults and aerodigestive care. He innovates minimally invasive surgical techniques in the head and neck.  Dr. Wootten is actively investigating the role of eosinophil and mast cell-based inflammation in the pediatric larynx.

Karla O'Dell, M.D.

Assistant Professor / Co-director

USC Voice Center, Caruso Department of Otolaryngology Head and Neck Surgery @ University of Southern California / USC Center for Airway Intervention and Reconstruction

Karla O’Dell, MD, specializes in head and neck surgery and disorders of the voice, airway and swallowing. She is cofounder and codirector of the USC Airway Intervention & Reconstruction Center (USC Air Center).

Jeanne L. Hatcher, MD, FACS

Co-Director of the Emory Voice Center and Associate Professor of Otolaryngology

Emory University School of Medicine

Dr. Hatcher has been at Emory since 2014 after completing her laryngology fellowship with Dr. Blake Simpson; she specializes in open and endoscopic airway surgery as well as voice disorders. Dr. Hatcher is a member of the ABEA and post-graduate member of the ALA and also serves on the Ethics and Voice Committees for the American Academy of Otolaryngology Head and Neck Surgery.

Mr. Lee Aspland

Patient / Freelance Artist

Lee Aspland Photography

Lee Aspland is a photographer, author and mindful practitioner who creates photography that reflects his feelings about living in such a glorious world. He specializes in Mindful Photography, capturing a fleeting feeling or thought, a hope or fear, a frozen single moment in time.

Gemma Clunie, MSc, BA (Hon), MRCSLT

Clinical Specialist Speech-Language Pathologist (Airways/ENT) and HEE/NIHR Clinical Doctoral Research Fellow

Imperial College Healthcare NHS Trust/ Imperial College London, Department of Surgery & Cancer

Gemma is a Clinical Specialist Speech and Language Therapist with an interest in voice and swallowing disorders that is particularly focused on the benign ENT, head and neck, respiratory and critical care populations. Gemma is a current NIHR/HEE Clinical Doctoral Research Fellow at Imperial College London. Her PhD studies focus on the voice and swallowing difficulties of airway stenosis patients. She is based at Charing Cross Hospital in London where she has worked for the last six years as part of the National Centre for Airway Reconstruction, Europe’s largest centre for the management of airway disorders.

Niall C. Anderson, CPsychol, MSc, BSc

Lead Psychologist (formerly Respiratory Highly Specialist Health Psychologist)

Bart's Health NHS Trust (formerly Central & North West London NHS Foundation Trust)

Niall is a HCPC Registered & BPS Chartered Practitioner Health Psychologist, and BPS RAPPS Registered Supervisor. Niall has specialist experience of working within healthcare systems with people with long-term health conditions at all system levels to support physical, psychological and social wellbeing. Niall worked in the Airway Service at Charing Cross Hospital (London, UK) between January-December 2021 in order to develop and implement the Airway Psychology Service.

Introducing a Two-Part Sialendoscopy Series!

Brought to you by our partnership with Cook Medical, we are having a two-part series on Sialendoscopy. The sessions will feed into one another, the first covering basics like a review of instrumentation and set up, as well as some of the most basic interventions you will see.

The second session will assume a basic knowledge of the procedure and will deal with complex interventions including both endoscopic and combined open procedures, advanced radiology, and complication management for revision surgery and in-office procedures.

Meet the Course Directors!

Rohan R. Walvekar, MD

Assistant Professor in Head Neck Surgery

University of Pittsburgh/VA Medical Center

Rohan R. Walvekar, MD, earned his doctoral degree from the University of Mumbai. After graduating in 1998, he completed a residency in Otolaryngology and Head Neck Surgery at the TN Medical College & BYL Nair Charitable Hospital, Mumbai, India, with triple honors. Subsequently, he completed two head neck surgery fellowships, and trained at at the Tata Memorial Hospital, Mumbai, which is India's most prestigious cancer institute. After completing an Advanced Head Neck Oncologic Surgery fellowship at the University of Pittsburgh, he became an Assistant Professor in Head Neck Surgery within the Department of Otolaryngology Head Neck Surgery at the University of Pittsburgh/VA Medical Center, prior to joining the LSU Health Sciences Center in July 2008. His clinical interests are head neck surgery and salivary endoscopy. His research interests include evaluating prognostic markers and clinical outcomes of head and neck cancer therapy and treatment of salivary gland disorders.

Barry M Schaitkin, MD

Professor of Otolaryngology

UPMC Pittsburgh

Dr. Schaitkin specializes in the treatment of inflammatory and neoplastic conditions of the salivary glands. He practices at UPMC in the Department of Otolaryngology and is affiliated with UPMC branches all across the city of Pittsburgh. He completed his medical degree and residency at Pennsylvania State University College of Medicine.

Meet the Presenters!

Jolie Chang, MD

Associate Professor, Chief of Sleep Surgery and General Otolaryngology

University of California, San Francisco

Dr. Chang specializes in sleep apnea surgery and minimally invasive approaches to the salivary duct with sialendoscopy. She has interest in studying patient reported outcomes after sialendoscopy procedures.

Mark Marzouk, MD

Clinical Associate Professor of Otolaryngology - Head and Neck Surgery

SUNY Upstate Medical University

Dr. Marzouk completed his residency training in 2010 from the UPMC Department of Otolaryngology. He is currently the Division Chief of Head and Neck Oncologic Surgery in Syracuse. He is also the Associate Program Director of Residency Programs.

David W. Eisele, MD. FACS

Andelot Professor and Director - Department of Otolaryngology-Head and Neck Surgery

Johns Hopkins University School of Medicine

Dr. Eisele is the Past-President of the American Board of Otolaryngology- Head and Neck Surgery and a member of the NCCN Head and Neck Cancer Panel. He has served as a member of the Residency Review Committee for Otolaryngology, as Chair of the Advisory Council for Otolaryngology - Head and Neck Surgery for the American College of Surgeons, President of the American Head and Neck Society, and as Vice-President of the Triological Society. He served as President of the Maryland Society of Otolaryngology and is a former Governor of the American College of Surgeons.

M. Boyd Gillespie, MD, MSc, FACS

Professor and Chair

UTHSC Otolaryngology-Head and Neck Surgery

M. Boyd Gillespie is Professor and Chair of Otolaryngology-Head & Neck Surgery at University of Tennessee Health Science Center. He is a graduate of the Johns Hopkins University School of Medicine where he a completed residency and fellowship in Otolaryngology-Head & Neck Surgery. Dr. Gillespie earned a Masters in Clinical Research at the Medical University of South Carolina, and is board certified in Otolaryngology-Head and Neck Surgery and Sleep Medicine. He has published over 150 academic papers and is editor of the textbook Gland-Preserving Salivary Surgery: A Problem-Based Approach. He is a former Director of the American Board of Otolaryngology-Head & Neck Surgery (ABOHNS) and current member of the otolaryngology section of the Accreditation Council for Graduate Medical Education (ACGME).

M. Allison Ogden, MD FACS

Professor & Vice-Chair of Clinical Operations - Department of Otolaryngology

Washington University School of Medicine

Dr. Ogden is a Professor and Vice-Chair of Clinical Operations in the Department of Otolaryngology at Washington University School of Medicine. She graduated from the Washington University School of Medicine in 2002 and went on to complete her residency there as well in Otolaryngology in 2007. Her clinical interests include sialendoscopy, nasal obstructions, and hearling loss. In 2015 Dr. Ogden was listed in "Best Doctors in America", an honor that continues to this day.

Arjun S. Joshi, MD

Professor of Surgery

The George Washington University School of Medicine & Health Sciences

Arjun Joshi, MD is board-certified in Otolaryngology and Head & Neck surgery by both the American Board of Otolaryngology – Head and Neck Surgery and the Royal College of Physicians and Surgeons of Canada. Dr. Joshi received his medical degree from the State University of New York at Syracuse and completed his residency at The George Washington University Medical Center. His areas of expertise include: Head and Neck Cancer, Head and Neck Masses, Head and Neck Reconstruction, Thyroid and Parathyroid Surgery, and Salivary Endoscopy.

Henry T. Hoffman, MD

Professor of Otolaryngology / Professor of Radiation Oncology

University of Iowa Healthcare

Dr. Henry T. Hoffman is an ENT-otolaryngologist in Iowa City, Iowa and is affiliated with University of Iowa Hospitals and Clinics. He received his medical degree from University of California San Diego School of Medicine and has been in practice for more than 20 years.

David M. Cognetti, MD, FACS

Professor and Chair of Department of Otolaryngology-Head & Neck Surgery

Thomas Jefferson University

Dr. Cognetti received his BS in Biology from Georgetown University and his MD from the University of Pittsburgh School of Medicine. He completed a residency in Otolaryngology – Head and Neck Surgery at Thomas Jefferson University before completing a fellowship in Advanced Head and Neck Oncologic Surgery at the University of Pittsburgh Medical Center. Dr. Cognetti returned to Jefferson, his professional home, as faculty in 2008.

A nurse was just sentenced to 3 years of probation for a lethal medical error

RaDonda Vaught’s conviction set a dangerous precedent for patient safety, but is also driving a push for better protections for nurses.

By Keren Landman@landmanspeaking May 13, 2022, 4:00pm EDT

RaDonda Vaught, whose criminal prosecution for a fatal medical error made her case a flashpoint in national conversations about nursing shortages and patient safety, was sentenced on Friday to three years of probation in a Nashville criminal court. After the probationary period, she could ultimately have her conviction dismissed.

Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult, which together carried a potential prison sentence of up to eight years.

In late 2017, Vaught, a nurse, mistakenly administered the wrong medication to patient Charlene Murphey while Murphey awaited a radiologic study at Vanderbilt University Medical Center. Murphey died as a consequence of the error, and an investigation later found that multiple patient safeguards that should have existed in the hospital had been absent or failing at the time of the event and were partially responsible for her death.

Vaught’s errors included removing the wrong medication from one of the hospital’s electronic prescribing cabinets, overlooking several warnings on the medication vial, and not monitoring Murphey’s vital signs after administering the medication.

What made Vaught’s case notable was that she was prosecuted in criminal court, a decision made by the Nashville district attorney. Most nursing malpractice cases are disciplined through state nursing boards, which can revoke professional licenses. If legal action is taken in nursing errors, it is generally through civil courts, where patients and families can obtain financial compensation.

Vaught’s case was also notable because while she was charged with a crime, her employer — Vanderbilt University Medical Center — faced fewer consequences.

A federal investigation found that at the time Vaught made the error, gaps in the hospital’s patient safety policies and systems constituted an immediate threat to patients.

While the hospital settled a civil case out of court with Murphey’s family, it has not been held criminally liable. And while the Tennessee health department revoked Vaught’s license, it did not punish the hospital, although the Tennessee Bureau of Investigation found multiple instances of wrongdoing and cover-ups on the hospital’s part.

Although the sentencing was lenient, patient safety advocates and nursing groups are upset about the case, and say it sets a bad precedent: because Vaught individually took the fall for a systematic failure.

Punishing individuals for systemic safety failures is concerning to patient safety advocates because it is ultimately detrimental to patient safety.

Why punishing nurses for medication errors can make patients less safe

For decades, scholars have understood that keeping patients safe requires continually improving the systems that prevent and catch medical errors before they happen. Critically, those systems cannot improve if the people within them don’t feel safe reporting problems.

One of the biggest concerns among patient safety experts is that severe punishment for medical errors — as in Vaught’s case — will lead to reduced error reporting by other nurses due to fear of being fired, or fear of prosecution. That could lead systemic problems to persist unfixed, which would be worse for patient safety.

In an April interview, Robert Gatter, a health law expert at Saint Louis University, said Vaught’s prosecution was a smokescreen that distracted from her employer’s inadequate safety systems. “They can forever now point to this person and say, ‘Wow, she is so bad,’” he said, rather than being held accountable for having a broken patient safety infrastructure.

Vaught’s case is one of several recent cases in which criminal charges were levied against nurses in settings ranging from jails to nursing homes. Many nurses say this trend, combined with the stresses of the pandemic and preexisting nursing shortages, has exacerbated already low morale among nurses.

Anecdotally, their disillusionment is leading many nurses to leave patient care roles. But there are signs Vaught’s verdict might be an inflection point for broader patient safety efforts.

Kedar Mate, a physician who is president of the Institute for Healthcare Improvement, recalls a recent anecdotal example of the case’s potential chilling effect among medical professionals. He was in an audience for a talk on patient safety in a room full of doctors and nurses. When the speaker asked how many of the attendees had reported a medical error, most of the hands in the room went up — and when he asked how many would do it now, in light of the Vaught case, most of the hands went down. “It’s had a very significant effect,” he said, although there isn’t hard data to cite here.https://e578181f53bd8b03e1e33f82a408238f.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html

Mate said several hospital CEOs — for example, the leadership of Northern Virginia’s Inova Health — are trying to head off that concern by communicating directly with employees. “Health system leaders are issuing statements, supporting their staff to come forward transparently to report — in essence, saying that ‘We hear and see what’s going on in Tennessee. In our system, we value transparent, candid, open, honest reporting of near misses and adverse events.’”

It’s hard to know what the outcome of that outreach will be. Rates of medical errors — and measures of staff willingness to report them — are only revealed over time.

“We’re not going to know for a little while whether this is going to have an effect,” said Mate of Vaught’s case.

The case is inspiring calls for policies that support nurses, and patients

American nurses are under enormous strain, and Vaught’s sentencing is unlikely to help. However, the case has directed attention to policies and legislations that would help prevent medical errors in the first place.

For one, the case has energized efforts to establish a National Patient Safety Board (NPSB), which would function much the way the National Transportation Safety Board does by reviewing data on medical errors and close calls with the highest likelihood of causing patient harm. The NPSB would then make recommendations for solutions and corrective actions that would prevent further bad outcomes for patients.

Karen Feinstein, leader of the advocacy coalition supporting the board’s creation, said she now uses Vaught’s case as an example of why the agency is necessary. “If you had an NPSB,” she said, “I don’t believe an accident like this would happen.”

An estimated 7,000 to 9,000 people die in the US each year as a result of a medication error. With a national board in place, many factors that contributed to the error that killed Charlene Murphey could have been identified in advance, including persistent software problems that weakened automated safety checks during medication dispensing, and Vaught’s distraction by an orientee (Vaught had been multitasking when the error occurred, helping with nursing needs across her unit and orienting a new employee).

Nurse-to-patient ratios are an important determinant of patient safety, and bills aimed at ensuring safer staffing ratios are making their way through the House and Senate. At the National Nurses March in Washington, DC, yesterday, many of those marching expressed support for the bills. The powerful hospital lobby is likely to oppose the legislation, lowering its chances of success, said a senior congressional staffer who requested anonymity to speak candidly about the bill. But nurses and nurses unions in several states are advocating for its passage.

On the day of the sentencing, hundreds of nurses gathered across the street from the Nashville municipal courthouse to support Vaught, a purple banner reading “We are nurses not criminals” on display. They held hands as they listened to a live broadcast of Judge Jennifer Smith’s decision, and erupted in cheers as the sentence was read.

Julie Griffin, a Florida nurse who was fired in 2018 after making complaints about unsafe staffing and monitoring procedures at the medical center where she worked, attended the rally. After the sentence was handed down, she said she felt ambivalent. “I mean, it’s a great verdict,” she said, “on a charge that should never have been imposed.”

The sentence notwithstanding, the case had already done damage to the nursing profession, said Griffin. Nurses were walking away from the profession before Vaught’s April verdict, but the case has intensified the sense of alienation for many, she said.

“The health care system needs to look in towards itself and start promoting a culture where nurses are allowed to speak up — to effect change before these things happen,” she said.

Read the source material for this article on vox.com.