Juliane Bingener

Mayo Clinic - Rochester, Рочестер, Minnesota, United States

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Publications (96)385.95 Total impact

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    ABSTRACT: Introduction: To improve a common source of communication breakdown in patient care, the Institute for Healthcare Improvement published a standardized handoff communication tool known as ‘SBAR’ (Situation (S), Background (B), Assessment (A) and Recommendation (R)). This study explored the use of SBAR for handoffs between surgical team members 6 years after implementation in a large tertiary care center. Methods: Healthcare systems engineering researchers observed 23 operative procedures in June 2015. Case duration, presence and duration of handoffs, were recorded for the following participants – circulating registered nurses (RN), certified surgical technicians (CST), certified surgical assistants (CSA), and anesthesia providers including certified registered nurse anesthetist and anesthesiologists (CRNA/ANES). To evaluate the use of SBAR during handoffs, a binary approach to determine existence or nonexistence of each SBAR component (S, B, A, R) was applied and analyzed using nonparametric statistics. Results: Of the 23 procedures (M = 219 min, SD = 92), 20 included at least one handoff during the operative procedure. Within these 20 cases, 127 handoffs were observed of which 119 could be assessed for SBAR use. CSAs performed fewer handoffs (10%) than CSTs (26%), anesthesia providers (30%) and RNs (34%) (p=0.0014). Of the 119 handoffs (M = 61sec, SD = 52), 90% included information about the patient’s situation, 58% discussed clinical background, 64% provided an assessment and 55% made a recommendation. SBAR components included in each handoff varied significantly by the role involved; specifically differences exist between CRNA/ANES and CSAs when evaluating use of ‘B’ (p=0.032), ‘A’ (p=0.048) and average number of SBAR factors included (p=0.043). When the core team member present at the start of the case handed off, information about the situation was included in 94%, background in 69%, assessment in 68% and recommendation in 68% of handoffs. The average number of SBAR factors used differed by who provided the handoff (original →relief, relief →original, relief →relief) (p=0 .0018), driven by the use of ‘B’. Conclusion: This pilot study suggests that in a busy OR a handoff by a team member may occur every 35 minutes and adoption of the SBAR structure during surgical procedures differs by role and situation. Team members adjusted for prior knowledge (e.g. ‘B’) by the core team. The study was not scoped to investigate the effect of surgeon briefings on the differential use of SBAR or the effect of differential use of SBAR on the occurrence of non-routine events.
    No preview · Conference Paper · Feb 2016
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    ABSTRACT: Background: Laparoscopic tool handles causing wrist flexion and extension more than 15° from neutral are considered "at risk" for musculoskeletal strain. Therefore, this study measured the impact of laparoscopic tool handle angles on wrist postures and task performance. Methods: Eight surgeons performed standard and modified Fundamentals of Laparoscopic Surgery (FLS) tasks with laparoscopic tools. Tool A had three adjustable handle angle configurations, i.e., in-line 0° (A0), 30° (A30), and pistol-grip 70° (A70). Tool B was a fixed pistol-grip grasper. Participants performed FLS peg transfer, inverted peg transfer, and inverted circle cut with each tool and handle angle. Inverted tasks were adapted from standard FLS tasks to simulate advanced tasks observed during abdominal wall surgeries, e.g., ventral hernia. Motion tracking, video analysis, and modified NASA-TLX workload questionnaires were used to measure postures, performance (e.g., completion time and errors), and workload. Results: Task performance did not differ between tools. For FLS peg transfer, self-reported physical workload was lower for B than for A70, and mean wrist postures showed significantly higher flexion for in-line than for pistol-grip tools (B and A70). For inverted peg transfer, workload was higher for all configurations. However, less time was spent in at-risk wrist postures for in-line (47 %) than for pistol-grip (93-94 %), and most participants preferred Tool A. For inverted circle cut, workload did not vary across configurations, mean wrist posture was 10° closer to neutral for A0 than B, and median time in at-risk wrist postures was significantly less for A0 (43 %) than for B (87 %). Conclusion: The best ergonomic wrist positions for FLS (floor) tasks are provided by pistol-grip tools and for tasks on the abdominal wall (ventral surface) by in-line handles. Adjustable handle angle laparoscopic tools can reduce ergonomic risks of musculoskeletal strain and allow versatility for tasks alternating between the floor and ceiling positions in a surgical trainer without impacting performance.
    No preview · Article · Nov 2015 · Surgical Endoscopy

  • No preview · Article · Oct 2015 · Hernia

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
    Full-text · Article · Sep 2015 · The Lancet
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    Adam Gyedu · Setri Fugar · Raymond Price · Juliane Bingener
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    ABSTRACT: Introduction: Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it. Methods: A cross-sectional survey was conducted among patients attending specialist clinics at KATH. Results: 1070 patients participated. Mean age was 40±15years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients' willingness to pay more for laparoscopy. Conclusion: Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.
    Full-text · Article · Aug 2015 · Pan African Medical Journal
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    Terry P Nickerson · Aodhnait S Fahy · Juliane Bingener
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    ABSTRACT: Hemangiopericytoma (HPC) is a rare mesenchymal tumor derived from capillary and postcapillary pericytes that often has an indolent course and occasionally presents with abdominal metastasis. Twenty-three years after the initial resection of an intracranial HPC located in the right frontoparietal region and left lateral ventricle, a 63-year-old man experienced dull abdominal pain and early satiety and had a palpable epigastric mass. Computed tomography indicated a suspected metastasis of HPC to the left upper abdomen. On laparoscopic exploration, the tumor was found in the falciform ligament and was excised laparoscopically per request of the patient. He had a fast recovery and experienced good relief of his pain and satiety. The patient had 2 additional metastases at his 12-month follow-up, both in the right retroperitoneum, and he again underwent laparoscopic resection. At his next annual follow-up, new metastases were identified in his liver, small-bowel mesentery, and peritoneal surface, prompting a trial of systemic chemotherapy. Because of progress of a left lower abdominal preperitoneal metastasis on follow-up at 3 years, the patient underwent a further successful laparoscopic exploration. Postoperatively, systemic chemotherapy was maintained. We report the recurrent laparoscopic resection of peritoneal metastases of primary intracranial HPC with good symptom control and fast recovery. Both the patient and the referring physician requested a minimally invasive surgical approach. Laparoscopic resection is a feasible treatment strategy for intraperitoneal metastases and is effective in symptom palliation. Copyright © 2015. Published by Elsevier Ltd.
    Preview · Article · Jul 2015 · International Journal of Surgery Case Reports
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    ABSTRACT: Single-incision laparoscopic cholecystectomy (SILC) may lead to higher patient satisfaction; however, SILC may expose the surgeon to increased workload. The goal of this study was to compare surgeon stress and workload between SILC and conventional laparoscopic cholecystectomy (CLC). During a double-blind randomized controlled trial comparing patient outcomes for SILC versus CLC (NCT0148943), surgeon workload was assessed by four measures: surgery task load index questionnaire (Surg-TLX), maximum heart rate, salivary cortisol level, and instruments usability survey. The maximum heart rate and salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, intraoperatively after the cystic duct was clipped, and at skin closure. After each procedure, the surgeon completed the Surg-TLX and an instrument usability survey. Student's t tests, Wilcoxon rank sum test, and Kruskal-Wallis nonparametric ANOVAs on the dependent variables by the technique (SILC vs. CLC) were performed with α = 0.05. Twenty-three SILC and 25 CLC procedures were included in the intent-to-treat analysis. No significant differences were observed between SILC and CLC for patient demographics and procedure duration. SILC had significantly higher post-surgery surgeon maximum heart rates than CLC (p < 0.05). SILC also had significantly higher mean change in the maximum heart rate between during and post-procedure (p < 0.05) than CLC. Salivary cortisol level was significantly higher during SILC than CLC (p < 0.01). Awkward manipulation of the instruments and limited fine motions were reported significantly more frequently with SILC than CLC (p < 0.01). In the surgeon-reported Surg-TLX, subscale of physical demand was significantly more demanding for SILC than CLC (p < 0.05). Surgeon heart rate, salivary cortisol level, instrument usability, and Surg-TLX ratings indicate that SILC is significantly more stressful and physically demanding than the CLC. Surgeon stress and workload may impact patients' outcomes; thus, ergonomic improvement on SILC is necessary.
    Full-text · Article · Jul 2015 · Surgical Endoscopy
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    ABSTRACT: Centers for Medicare and Medicaid Services define laparoscopic ventral hernia repair (LVHR) as outpatient procedure. We identified our institutional length of stay (LOS) to be above the National Surgical Quality Improvement Program (NSQIP) benchmark of 1 day [interquartile range (IQR) 2 days]. This study was undertaken to investigate risk factors associated with prolonged hospital stay and design an intervention to decrease median LOS. This study analyzed institutional NSQIP data on patients who underwent elective LVHR from 2006 to 2011 to define factors associated with prolonged LOS, defined as LOS > 2 days. Modifiable factors identified in the initial analysis were included in a clinical care pathway to impact LOS. We repeated the NSQIP data analysis after implementation (4/2011-9/2012) to assess the effect of our intervention. Analysis was by univariate, ANOVA and logistic regression models. During the pre-implementation period, 80 patients with a median age of 54 years (31-84) stayed a median of 2 days (IQR 3). On univariate analysis, factors associated with prolonged LOS included operative time, mesh size, amount of narcotics used and female gender. In multivariate analysis, operative time and narcotics used were associated with a prolonged LOS, C statistic = 0.88. Introduction of a clinical pathway focusing on non-narcotic pain relief resulted in a decrease in mean narcotic usage from 223 to 63 mg morphine equivalents/patient (p < 0.0001), decrease in median LOS to 1 day (IQR 2) (p = 0.027), in line with NSQIP benchmarks, a slight decrease in complications and a 10 % decrease in hospital cost. High narcotic use and long operative times are independent predictors of prolonged LOS in our patient population. Introduction of a standardized clinical care pathway designed to reduce perioperative narcotic use resulted in shorter LOS, improved quality and cost savings for patients undergoing LVHR.
    No preview · Article · Jul 2015 · Surgical Endoscopy
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    ABSTRACT: We report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS). From August 2009 to August 2014, operative and invasive procedural "Never Events" (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using the 4 levels of error causation described by Reason and 161 HFACS subcategories (nano-codes). During the study, approximately 1.5 million procedures were performed, during which 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors (n = 260) and preconditions to actions (n = 296) accounted for the majority of the nano-codes across all 4 types of events, with individual cognitive factors contributing one half of the nano-codes. The most common action nano-codes were confirmation bias (n = 36) and failed to understand (n = 36). The most common precondition nano-codes were channeled attention on a single issue (n = 33) and inadequate communication (n = 30). Targeting quality and interventions in system improvement addressing cognitive factors and team resource management as well as perceptual biases may decrease errors and further improve patient safety. These results delineate targets to further decrease never events from our health care system. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · May 2015 · Surgery
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    ABSTRACT: Aim. Sex-based differences in surgical outcomes may be related to socioeconomic, behavioral, or physiologic factors. Estrogenreceptor-related modulation is a proposed mechanism for sex-based differences in reaction to inflammation. We evaluated sex-based differences in gallbladder tissue-levels of inflammatory cytokines using a novel method to collect interstitial fluid from cholecystectomy samples. Methods. Patients undergoing laparoscopic cholecystectomy for acute or chronic cholecystitis were prospectively enrolled from August 1, 2006, through August 1, 2009. Immediately after gallbladder removal, interstitial fluid from the gallbladder fundus and infundibulum was collected. Tissue-level cytokines were determined using a multiplex cytometric bead assay. Messenger RNA levels of estrogen receptors and aromatase (ESR1, GPER, CYP19A1) were analyzed with real-time reverse transcriptasepolymerase chain reaction. Results. Interstitial fluid from gallbladder tissue of 78 patients (48 women) was analyzed. All patients with acute cholecystitis had higher levels of interleukin (IL)-6 and IL-10 than patients with chronic cholecystitis. Men with acute disease had higher tissue levels of IL-6 and IL-8 than women. IL-1β and IL-10 were increased only in men with acute cholecystitis. Tumor necrosis factor-α levels did not vary by sex or disease status. Tissues from acutely inflamed gallbladders had higher expression of a G protein-coupled estrogen receptor (GPER) and aromatase (CYP19A1). Conclusion. Tissue-level proinflammatory cytokines differ between men and women with acute cholecystitis. Mechanistic studies are needed to determine whether changes in cytokine levels or estrogen function contribute to local tissue inflammation and whether these influence surgical outcomes.
    No preview · Article · Apr 2015
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    ABSTRACT: Self-directed learning (SDL) can be as effective as instructor-led training. It employs less instructional resources and is potentially a more efficient educational approach. Although SDL is encouraged among residents in our surgical training program via 24-hour access to surgical task trainers and online modules, residents report that they seldom practice. We hypothesized that a mentor-guided SDL approach would improve practice habits among our residents. From 2011 to 2013, 12 postgraduate year (PGY)-2 general surgery residents participated in a 6-week minimally invasive surgery (MIS) rotation. At the start of the rotation, residents were asked to practice laparoscopic skills until they reached peak performance in at least 3 consecutive attempts at a task (individual proficiency). Trainees met with the staff surgeon at weeks 3 and 6 to evaluate progress and review a graph of their individual learning curve. All trainees subsequently completed a survey addressing their practice habits and suggestions for improvement of the curriculum. By the end of the rotation, 100% of participants improved in all practiced tasks (p < 0.05), and each reported that they practiced more in this rotation than during rotations without mentor-guided SDL. Additionally, 6 (50%) residents reported that their skill level had improved relative to their peers. Some residents (n = 3) felt that the curriculum could be improved by including task-specific goals and additional practice sessions with the staff surgeon. Mentor-guided SDL stimulated surgical residents to practice with greater frequency. This repeated deliberate practice led to significantly improved MIS skills without significantly increasing the need for faculty-led instruction. Some residents preferred more discrete goal setting and increased mentor guidance. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Mar 2015 · Journal of Surgical Education
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    ABSTRACT: Erratum to: Surg Endosc (2015) 29:289-321 DOI 10.1007/s00464-014-3917-8The name of the 14th author F. Koeckerling is misspelled. The correct spelling is F. Köckerling.
    Full-text · Article · Mar 2015 · Surgical Endoscopy
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    ABSTRACT: We tested the responsiveness of the National Institutes of Health-sponsored Patient-Reported Outcomes Measures Information System (PROMIS) global health short form and a linear analog self-assessment for laparoscopy. From May 2011 through December 2013, patients undergoing laparoscopy responded to patient reported outcome questionnaires perioperatively. Composite and single item scores were compared. One hundred fifteen patients, mean age 55 years, 58 % female, were enrolled. Visual analog pain scores differed significantly from baseline (mean 1.7 ± 2.3) to postoperative day 1 (mean 4.8 ± 2.6) and 7 (mean 2.5 ± 2.1) (p < 0.0001). PROMIS physical subscale and total physical component subscore differed significantly from baseline (14.4 ± 3.0/47.4 ± 8.3) to postoperative day 1 (12.7 ± 3.2/42.1 ± 8.8) (p = 0.0007/0.0003), due to everyday physical activities (p = 0.0001). Linear analog self-assessment scores differed from baseline for pain frequency (p < 0.0001), pain severity (p < 0.0001), and social activity (p = 0.0052); 40 % of subjects reported worsening in PROMIS physical T-score to postoperative day 1 and 25 % to postoperative day 7. Linear analog self-assessment mental well-being scores were worse in 32 % of patients at postoperative day 7, emotional well-being in 28 %, social activity in 24 %, and fatigue in 20 % of patients. Single items and change from baseline are responsive perioperative quality of life assessments for laparoscopy.
    No preview · Article · Mar 2015 · Journal of Gastrointestinal Surgery
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    ABSTRACT: The Institute of Medicine has included the comparison of minimally invasive surgical techniques in its research agenda. This study seeks to evaluate a model for the comparison of minimally invasive procedures using patient-reported outcomes. A double-blinded randomized controlled trial (NCT01489436) was conducted. Baseline data were obtained, standardized anesthesia was induced, and patients were randomized to single-port (SP) or 4-port (FP) laparoscopic cholecystectomy. Perioperative care was standardized. The outcomes were pain (Visual Analog Scale) on postoperative day 1 (primary) and quality of life (Patient-Reported Outcomes Measures Information System and Linear Analog Self-Assessment), serum cytokines, and heart rate variability (secondary). Analysis was intention to treat. Using identical occlusive dressings, patients and the outcomes assessor remained blinded until postoperative day 2. Fifty-five patients were randomized to each arm. There was no difference in demographics. Visual Analog Scale pain score on postoperative day 1 was significantly different from baseline in each group (SP: 1.6 ± 1.9 to 4.2 ± 2.4 vs FP: 1.8 ± 2.3 to 4.2 ± 2.2), but not different from each other (p = 0.83). Patients in the FP arm reported significantly less fatigue on postoperative day 7 than patients in the SP group (3.1 ± 2.1 vs 4.2 ± 2.2; p = 0.009). Fewer patients in the FP group required postoperative oral narcotics before discharge (40% vs 60%; p = 0.056). Cytokines levels and heart rate variability were similar between arms. In patients followed for >1 year, no difference in umbilical hernia rates was noted. Early postoperative quality of life data captured differences in fatigue, indicating improved recovery after FP within a controlled trial. Physiologic measures were similar, suggesting that the differences between SP and FP are minimal. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Mar 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Our previous work revealed significantly less acidosis in swine undergoing natural orifice translumenal endoscopic surgery (NOTES) using endoscopic air insufflation than swine undergoing standard laparoscopy. We wanted to evaluate the differential effects of CO2 versus intra-abdominal pressure as source for this finding. In addition, we investigated the endocrine stress response between swine undergoing NOTES peritoneoscopy with CO2 insufflation and animals undergoing standard diagnostic laparoscopy with CO2. Twenty-eight (28) female 50-kg domestic pigs were randomly assigned to one of four groups using a permuted block randomization table: Group 1: NOTES using CO2 insufflation, Group 2: NOTES using air insufflation, Group 3: laparoscopy max pressure 12 mmHg and Group 4: laparoscopy with max pressure 7 mmHg. Invasive monitoring lines were placed. Pneumoperitoneum was established by the respective method and maintained for 90 min, visualizing liver, spleen and colon. Arterial blood gas was obtained at baseline and four additional time points. Serum TNF-α for POD (postoperative day) 1 and cumulative urine adrenaline for the procedure were determined by ELISA. ANOVA and t test were used for statistical comparison. The study was Institutional Animal Care and Use Committees approved. All experiments were completed as outlined. Blood pH showed a significant difference between groups. Serum TNF-α revealed higher levels for NOTES CO2 on POD 1 than standard laparoscopy (p = 0.03). NOTES animals with CO2 insufflation initially experienced similar pH compared to standard laparoscopy but recovered to levels seen in low-pressure laparoscopy and NOTES with air. NOTES with CO2 appears to elicit a stronger stress response in this study than standard or low-pressure laparoscopy or NOTES with air.
    No preview · Article · Feb 2015 · Surgical Endoscopy

  • No preview · Article · Oct 2014 · Journal of the American College of Surgeons

Publication Stats

843 Citations
385.95 Total Impact Points

Institutions

  • 2008-2015
    • Mayo Clinic - Rochester
      • Department of Surgery
      Рочестер, Minnesota, United States
  • 2013
    • Baylor College of Medicine
      Houston, Texas, United States
  • 2003-2008
    • University of Texas Health Science Center at San Antonio
      • Department of Surgery
      San Antonio, Texas, United States
    • University of Texas at San Antonio
      San Antonio, Texas, United States