Timothy M Farrell

University of North Carolina at Chapel Hill, North Carolina, United States

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Publications (66)208.08 Total impact

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    ABSTRACT: BACKGROUND: The objective of this study was to examine the acquisition of advanced laparoscopic technical and cognitive skills during a fellowship. METHODS: During a yearlong fellowship, consecutive assessments were completed by a fellow and 1 attending for 3 advanced procedures. The Global Operative Assessment of Laparoscopic Skills, Objective Structured Assessment of Technical Skills, and procedure-specific rating tools and free-text feedback were used. Descriptive statistics, the t test, linear mixed-effects regression, and qualitative analysis of feedback were performed. RESULTS: Seventy-six cases were included. Average ratings increased for each assessment area every month (P < .001). There were significant differences between ratings by assessors with more stringent ratings by the fellow. While the attending focused on efficiency and safety, the fellow focused on technical issues, with later expanded attention to advanced cognitive aspects. CONCLUSIONS: These assessment tools can be used as a quantitative index to monitor fellows learning curve. In combination with narrative feedback, such data can provide measures to direct improvement during self-directed learning.
    The American Journal of Surgery 10/2014; DOI:10.1016/j.amjsurg.2014.08.029 · 2.41 Impact Factor
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    ABSTRACT: Postcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy. A retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001 and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed. Twelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months (range 0.5-168 months). On a standard liver enzyme panel, 75 % of patients had derangements in ≥1 indices, with the most common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80 %). Eight operative reports noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak (Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and six were managed endoscopically. RCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.
    Journal of Gastrointestinal Surgery 05/2014; 18(7). DOI:10.1007/s11605-014-2530-4 · 2.39 Impact Factor
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    ABSTRACT: The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity. Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency. A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills. A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables. This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.
    Annals of surgery 01/2014; 261(2). DOI:10.1097/SLA.0000000000000520 · 7.19 Impact Factor
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    ABSTRACT: In an effort to fulfill its charge to develop and maintain a comprehensive educational program to serve the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the SAGES Continuing Education Committee (CEC) reports a summary of findings related to its evaluation of the 2012 SAGES annual meeting. All attendees to the 2012 annual meeting had the opportunity to complete an immediate postmeeting questionnaire as part of their continuing medical education (CME) certification in which they identified up to two learning themes, answered questions related to potential practice change items that are based on those learning themes, and complete a needs assessment related to important learning topics for future meetings. In addition, participants in the postgraduate and hands-on courses were asked to complete questions about case volume and comfort levels related to procedures/topics in those courses. All respondents to this initial survey were sent a 3-month follow-up questionnaire in which they were asked how successfully they had implemented the intended practice changes and what, if any, barriers they encountered. Postgraduate and hands-on course participants completed case volume and comfort level questions. Descriptive statistical analysis of this deidentified data was undertaken. Response rates were 42 % and 56 % for CME-eligible attendees/respondents for the immediate postmeeting and 3-month follow-up questionnaires, respectively. Top learning themes for respondents were Bariatric, Hernia, Foregut, and Colorectal. Improving minimally invasive surgical (MIS) technique and managing complications related to MIS procedures were top intended practice changes. Partial implementation was common with top barriers including cost restrictions, lack of institutional support, and lack of time. The 2012 annual meeting analysis provides insight into educational needs among respondents and will help with planning content for future meetings.
    Surgical Endoscopy 11/2013; 27(12). DOI:10.1007/s00464-013-3263-2 · 3.31 Impact Factor
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    ABSTRACT: PURPOSE: Data indicate that students are unprepared to perform basic medical procedures on graduation. The authors' aim was to characterize graduating students' experience with and opinions about these skills. METHOD: In 2011, an online survey queried 156 fourth-year medical students about their experience with, and actual and desired levels of competence for, nine procedural skills (Foley catheter insertion, nasogastric tube insertion, venipuncture, intravenous catheter insertion, arterial puncture, basic suturing, endotracheal intubation, lumbar puncture, and thoracentesis). Students self-reported competence on a four-point Likert scale (4 = independently performs skill; 1 = unable to perform skill). Data were analyzed by analysis of variance and Student t test. A five-point Likert scale was used to assess student confidence. RESULTS: One hundred thirty-four (86%) students responded. Two skills were performed more than two times by over 50% of students: Foley catheter insertion and suturing. Mean level of competence ranged from 3.13 ± 0.75 (Foley catheter insertion) to 1.7 ± 0.7 (thoracentesis). A gap in desired versus actual level of competence existed for all procedures (P < .0001). There was a correlation between the number of times a procedure had been performed and self-reported competence for all skills except arterial puncture and suturing. CONCLUSIONS: Participants had performed most skills infrequently and rated themselves as being unable to perform them without assistance. Strategies to improve student experience and competence of procedural skills must evolve to improve the technical competency of graduating students because their current competency varies widely.
    Academic medicine: journal of the Association of American Medical Colleges 03/2013; 88(5). DOI:10.1097/ACM.0b013e31828b0007 · 3.47 Impact Factor
  • Surgical Endoscopy 08/2012; 26(12). DOI:10.1007/s00464-012-2491-1 · 3.31 Impact Factor
  • Elias Darido · Timothy M Farrell
    Surgery for Obesity and Related Diseases 07/2012; DOI:10.1016/j.soard.2012.07.006 · 4.94 Impact Factor
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    ABSTRACT: Background. Bariatric surgery has increased across America. Venous access is difficult in these patients. Anesthesiologists often utilize valuable operating room (OR) time acquiring reliable intravenous lines. Our objective was to determine if outpatient central venous line (CVL) placement improves OR efficiency and professional reimbursement for CVL insertion. Methods. In our bariatric practice, selected surgery patients have outpatient CVLs placed during prophylactic vena cava filter placement. In a cohort of 268 gastric bypass patients operated between 1/01 and 11/06, we compared time-to-incision between 106 with pre-established CVLs and 162 without. In addition, we determined professional compensation rates for CVLs placed outpatient versus CVLs inserted in the OR. Results. Patients with preoperative (outpatient) CVLs required 35.6 ± 12.5 minutes to skin incision compared with 42.5 ± 13.9 minutes for controls (P < 0.0001), and 34.9% had skin incision in <30 minutes compared with 16.4% of controls. Radiologists collected 28.2% of outpatient billings for CPT code 36556, compared with anesthesiologists who collected <1% when placing CVLs in the OR. Conclusions. Outpatient CVLs prior to gastric bypass improve efficiency in the OR with earlier skin incision. Professional reimbursement is better for outpatient CVLs than intraoperative inpatient CVLs.
    07/2012; 2012(3):816871. DOI:10.5402/2012/816871
  • Mark Joseph · Michael Phillips · Timothy M Farrell · Christopher C Rupp
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    ABSTRACT: Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency. Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques. Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the resident's learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC. Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.
    Journal of Surgical Education 07/2012; 69(4):468-72. DOI:10.1016/j.jsurg.2012.03.006 · 1.39 Impact Factor
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    ABSTRACT: Learning procedural skills as a medical student has evolved, as task trainers and simulators are now ubiquitous. It is yet unclear whether they have supplanted bedside teaching or are adjuncts to it, and whether faculty or residents are responsible for student skills education in this era. In this study we sought to characterize the experience and opinions of both medical students and faculty on procedural skills training. Surveys were sent to clinical medical students and faculty at UNC Chapel Hill. Opinions on the ideal learning environment for basic procedural skills, as well as who serves as primary teacher, were gathered using a 4-point Likert scale. Responses were compared via Fisher exact test. A total of 237 students and 279 faculty responded. Third-year students were more likely to report simulation as the primary method of education (64%), compared to either fourth-year students (35%; P < 0.0001) or faculty (43%; P = 0.0018). Third- and fourth-year students were also more likely to report interns as a primary teacher (15% and 10%, respectively) as opposed to faculty (2%), and less likely to suggest faculty were the primary teacher (30% and 21%, respectively, versus 35%), P < 0.0001. Residents were the primary teachers for all three groups (55%, 70%, and 63% respectively). Our data suggest that both medical students and faculty recognize the utility of simulation in procedural skills training, but vary in the degree to which they think simulation is or should be the primary instructional tool. Both groups suggest residents are the primary teacher of these skills.
    Journal of Surgical Research 06/2012; 177(2):196-200. DOI:10.1016/j.jss.2012.05.084 · 2.12 Impact Factor
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    ABSTRACT: To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC). Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC. A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and χ analyses where appropriate. A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%. There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.
    Annals of surgery 06/2012; 256(1):1-6. DOI:10.1097/SLA.0b013e3182583fde · 7.19 Impact Factor
  • Elias Darido · D Wayne Overby · Kim A Brownley · Timothy M Farrell
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    ABSTRACT: Gastric fundus compliance allows stomach volume increase in response to food intake. Absence of this postprandial relaxation alters hormonal signals and induces early satiety and weight loss. This study demonstrates the effect of gastric fundus invagination on the growth rate of juvenile pigs. After institutional animal care and use committee approval, 15 juvenile pigs were divided into two groups. In the first group, six pigs were anesthetized, weighed, and submitted to laparotomy, stomach manipulation, and short gastric vessel ligation. This is the control group and is referred to as "Sham". In the second group, gastric fundus invagination was added by using a circular stapler. This is the procedure group and is designated as "GFI". Postoperatively, body weight and food intake were measured for 5 weeks. Pigs were euthanized and the stomachs examined. Growth patterns were compared. Three animals were excluded from the analysis. At the end of the 5-week study period, six GFI pigs had intact anastomosis with an invaginated fundus. The mean percent growth rate for the GFI group (54.2 ± 2.8 %) was significantly less than the Sham group (77.7 ± 4.9 %). Gastric fundus invagination significantly decreases the growth rate in juvenile pigs.
    Obesity Surgery 05/2012; 22(8):1293-7. DOI:10.1007/s11695-012-0666-4 · 3.74 Impact Factor
  • J.J. Dehmer · K.D. Amos · T.M. Farrell · A.A. Meyer · M.O. Meyers
    Journal of Surgical Research 02/2012; 172(2):219-220. DOI:10.1016/j.jss.2011.11.321 · 2.12 Impact Factor
  • J. Carr · J.J. Dehmer · K.D. Amos · T.M. Farrell · A.A. Meyer · M.O. Meyers
    Journal of Surgical Research 02/2012; 172(2):190. DOI:10.1016/j.jss.2011.11.081 · 2.12 Impact Factor
  • Surgical Endoscopy 11/2011; 26(2):296-311. DOI:10.1007/s00464-011-2017-2 · 3.31 Impact Factor
  • Elias F Darido · Timothy M Farrell
    World Journal of Surgery 09/2011; 35(12):2594-5. DOI:10.1007/s00268-011-1282-5 · 2.35 Impact Factor
  • Christopher C Rupp · Timothy M Farrell · Anthony A Meyer
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    ABSTRACT: Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a "two-port" technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. SILC was completed successfully in 87 per cent of patients. Operative times were found to be similar between SLC and SILC (75 and 76 minutes, respectively; P = 0.12). Operative blood loss, hospital stay, and short-term complications were not statistically different between SILC and SLC. Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.
    The American surgeon 07/2011; 77(7):916-21. · 0.92 Impact Factor
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    ABSTRACT: Opportunities for medical students to learn and perform technical skills during their clinical years have decreased. Alternative means to provide instruction are increasingly important. Third-year students were assigned to three weekly small group tutorial sessions during their surgery clerkship. One hour sessions covered the following: suturing/knot tying, tubes (Foley catheter/NG tube), and lines (i.v. placement/arterial puncture). Students used a self-reported checklist to report their experience performing these procedures in the hospital after being exposed to them in the skills sessions. These data were compared with results prior to the implementation of the skills curriculum. Results were compared by Fisher's exact test. Seventy-seven students had evaluable checklists during the control period, and 69 were evaluable during the study period. Participations in four specific skills were compared: Foley catheter placement, nasogastric tube insertion/removal, i.v. placement, and arterial stick. In all four skills, students were more likely to have performed the task after having been introduced to it in the skills sessions. For both Foley catheter placement (96% versus 90%; P = 0.05) and NG tube insertion/removal (70% versus 53%; P = 0.06) there was a trend toward a higher incidence of participation, although statistical significance was not met. However, for both IV placement (64% versus 18%; P = 0.0001) and arterial puncture (48% versus 18%; P = 0.0002) there were significant increases in participation between the study periods. These results suggest that a small group technical skills curriculum facilitates learning of specific technical skills and appears to increase participation in all of the skills taught and assessed. This may be one strategy to introduce students to technical skills during the surgery clerkship and improve participation of these skills in the hospital setting.
    Journal of Surgical Research 04/2011; 166(2):171-5. DOI:10.1016/j.jss.2010.05.019 · 2.12 Impact Factor
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    ABSTRACT: Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported. A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction. Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence. In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.
    Surgical Innovation 02/2011; 18(4):338-43. DOI:10.1177/1553350610397383 · 1.34 Impact Factor
  • Article: Reply.
    Geoffrey P Kohn · Joseph A Galanko · Timothy M Farrell
    Journal of the American College of Surgeons 11/2010; 211(5):688-9. DOI:10.1016/j.jamcollsurg.2010.07.022 · 4.45 Impact Factor