Guy J. Maddern

Background: Hernia repair can safely be provided as a same‐day procedure. However, despite advice from published guidelines, previous analyses of Australian data have shown low rates of same‐day surgery in private hospitals for hernia repairs. Methods: This study used aggregated administrative data for Medibank‐insured patients treated in Australian hospitals between 1 January 2015 and 31 December 2024 for surgical repairs of inguinal, femoral, or umbilical hernias to analyse trends in same‐day services. Results: The proportion of hernia procedures performed as same‐day separations increased over time, rising from 22.7% in 2015 to 31.0% in 2024 ( p < 0.001). The average length of stay (LOS) among patients requiring overnight admission remained stable (1.26 days in 2015; 1.23 days in 2024). Same‐day separations were most common for umbilical repairs (47.5%), compared with femoral (23.7%) and inguinal repairs (22.0%). Female patients had a higher proportion of same‐day separations (29.5%) compared with male patients (25.8%, p < 0.001), but a higher average LOS (1.31 days, p < 0.001). The use of same‐day surgery varied across hospital locations. Conclusions: Despite a groundswell of evidence, changes in surgical practice to adopt same‐day hernia repair for privately‐insured patients are happening very slowly and are well below the recommended target of 70%–80%. The rise in same‐day separations appears to reflect greater use of day‐case pathways rather than shorter hospital stays among patients requiring admission overnight. Variation across locations suggests opportunities to improve consistency in care delivery through system‐level changes, and for same‐day hernia repair to become routine practice across all hospitals in Australia.

Background: In contemporary medicine, time pressure, limited resourcing, human factors, and health literacy are barriers to delivering high-quality patient-centred care. Improving patient engagement may mitigate these barriers. This study evaluated the impact of the Personal Outpatient Worksheet and Educational Reference (POWER) form on patient engagement in the surgical outpatient setting. Methods: A multicentre, randomized clinical trial was conducted in two metropolitan hospitals between July 2022 and January 2025. Patients over 16 attending a general surgical outpatient appointment were eligible for inclusion. Participants were randomized into either intervention or control cohorts using a random number generator with 1 : 1 allocation stratified by sex. All participants underwent a surgical outpatient appointment, which was audio-visually recorded. The intervention cohort received a copy of the POWER form, a document with five suggested questions participants could ask during their appointment. The control cohort received standard care without the POWER form. Participants were telephoned one week after their appointment to complete a survey. The primary endpoint was patient recall, assessed by comparing survey responses with the recorded discussion, using an intention to treat analysis. Results: A total of 143 participants were recruited (71 participants to intervention, 72 to control). Ten participants (five in each group) withdrew and were excluded from analysis of the primary endpoint. Mean recall in the intervention cohort was 88% (95% confidence interval 83 to 92) compared with 31% (26 to 35) in the control group (P < 0.001). Conclusion: Use of the POWER form in the general surgical outpatient setting significantly improves patient recall. Registration number: ACTRN12625000075482 (https://www.anzctr.org.au/).

Clinical quality registries (CQRs) are central to improving surgical safety and quality by enabling systematic monitoring of outcomes and proactive identification of outliers. Published guidelines provide important advice on methods and activities for CQRs. Guideline flexibility allows for the varied and unique requirements of each CQR, but some aspects around guideline implementation are less certain, particularly for outlier management. In order to describe activities in Australia and the UK, searches were undertaken for published examples of CQR analysis and reporting of outliers and the subsequent management of outlier surgeons. There are many examples of high quality CQRs which actively report relevant performance indicators, with dashboards that show inter‐hospital variation including unwarranted (outlier) variance. A small number of reports from the UK provide insight to local responses to suspected outlier status, commonly identifying data errors or systemic failures of local care processes. In Australia, challenges include voluntary participation, incomplete datasets, varied benchmarks, complex governance across public and private systems, and in some the restrictions imposed by qualified privilege. Worryingly, no single body is responsible for the management of the outlier surgeon. Outlier management can build on existing governance practices such as morbidity and mortality meetings and professional development activities. The publication of outlier processes and outcomes provides transparency to participants and closes the feedback loop. Active participation in CQRs and effective local outlier management actions should be encouraged as part of quality improvement, to learn from mistakes, celebrate excellence, and improve patient outcomes.

Objective: This scoping review aimed to examine the existing literature on the long-term management of stable vulvar lichen sclerosus (VLS), with a focus on care settings, provider roles for long-term management of uncomplicated disease, and to identify gaps within these frameworks. Methods: PubMed, Embase, and Web of Science were searched from inception to August 2025. Eligible sources included original research studies, audits, surveys, clinical practice guidelines, and consensus statements published in English with full-text availability. Studies involving adult women with VLS that addressed models of care, follow-up or surveillance, and long-term management were included. Studies focusing exclusively on pediatric populations, nonvulvar lichen sclerosus, commentary-only articles, or management of high-risk or complicated disease (including prior vulvar neoplasia) were excluded. Relevant professional society guidelines and consensus documents not captured through database searching were identified through targeted grey literature review. Results: Thirty-two sources of evidence met the inclusion criteria. The literature was heterogeneous, comprising observational studies, audits, surveys, and national and international consensus guidelines. There was broad agreement regarding the principles of lifelong follow-up. Common barriers in implementation included missed follow-up, inadequate examination, unclear discharge and referral pathways, lack of diagnostic criteria, and limited patient and clinician knowledge. No studies evaluating long-term models of care were identified. Conclusions: This scoping review identified limited empirical evidence describing implemented models of care for the long-term management of stable, uncomplicated VLS. While there is broad agreement across guidelines regarding principles of lifelong follow-up, multiple studies consistently demonstrate gaps between recommended models of care and implemented practice.

Objectives: To describe clinician perspectives, priorities, and concerns regarding the development of a shared care model for long-term management of stable vulvar lichen sclerosus (VLS). Methods: A cross-sectional online survey was conducted of clinicians involved in managing VLS. Stable VLS was defined as controlled disease on maintenance topical corticosteroids, ≤5 self-managed flares per year, patient acceptance of chronic therapy, no history of neoplasia, and no vulvar biopsy within the preceding 12 months. Survey items assessed current models of long-term care, perceived need for expanded community-based follow-up, barriers to shared care, and views on the appropriateness and requirements for successful implementation. Quantitative data were analyzed descriptively, and free-text responses underwent thematic analysis. Ethics approval was obtained. Results: A total of 120 clinicians from 12 countries completed the survey, with 44.2% based in Australia. Respondents were predominantly gynecologists (51.3%) and dermatologists (27.7%), with most (68.1%) having more than 10 years’ experience managing VLS. Overall, 85.1% supported a shared care model, with 68.4% rating it very appropriate, and 16.7% somewhat appropriate . Major barriers related to primary care included time and resource pressures, limited VLS knowledge, and inconsistent genital examination. Barriers identified in the specialist setting included patient preference for specialist-led care, concerns about the ability of other providers to titrate topical steroids, difficulty re-accessing specialist-led care, and communication or documentation gaps. Conclusion: Vulvar specialists internationally support shared care for stable VLS, yet formal models remain rare. The barriers are largely structural and modifiable, underscoring the need for operationalized shared care frameworks.

Background: Hip fracture is a common, high‐risk condition over‐represented in surgical mortality audits, yet the contribution of non‐technical errors has not been examined. This study aimed to determine the number, characteristics and clinical context of non‐technical errors associated with patient death in hip fracture mortality to identify targets for improvement. Methods: A retrospective cohort study analysed all inpatient hip fracture mortalities reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2012 and 2019. Patient mortalities flagged with an adverse event or area of concern were independently reviewed using a validated non‐technical error classification tool. Outcomes included number and proportion of errors within this cohort, error type, temporal trends, clinical phase of occurrence and team responsibility. Results: Of 8414 orthopaedic mortalities, 510 were flagged with an adverse event or area of concern, including 255 hip fracture patients. Non‐technical errors associated with death were identified in 116/255 (45.5%) patients, with no meaningful change over time. Decision making errors were most common (47.9%), followed by situational awareness (35.2%), communication/teamwork (10.3%) and leadership errors (6.7%). Most errors occurred outside the operating theatre, with 60.6% pre‐operative and 28.5% post‐operative. Orthopaedics were responsible for 86% of single‐team errors and contributed to all multi‐team errors. Other specialties were responsible for 14% of single‐team errors and contributed to multi‐team errors. Conclusion: In this cohort non‐technical errors associated with death are common. Distinct patterns by clinical phase, error type and team involvement highlight actionable targets for interventions to improve surgical safety and reduce future errors associated with death.

Objective: To characterize the incidence, clinical phase, team responsibility, and behavioral drivers of non-technical errors (NTEs) associated with death in emergency general surgery to inform future NTS improvement strategies. Background Data: Deficiencies in surgical non-technical skills (NTS) contribute substantially to patient harm. Emergency general surgery is common, complex, and high-risk, yet characteristics of NTEs remain unknown. Methods: Retrospective cohort study including all emergency general surgical mortalities with an adverse event or area of concern from a national, mandated, peer-reviewed mortality audit (2012–2019). Cases were independently assessed by two reviewers using a validated tool to identify and characterize NTEs. Results: NTEs occurred in 790/1164 (67.9%) deaths, comprising 1053 unique errors. Situational awareness errors occurred most (518/1053, 49.3%), followed by decision-making errors (431/1053, 40.9%). Most errors arose from few recurring behaviors: for situational awareness, failure to recognize clinical signs (92/518, 17.8%), failure to appreciate illness severity (75/518, 14.5%), and missed diagnosis (73/518, 14.1%); for decision-making, failure to initiate appropriate intervention/investigation (99/431, 23%) or incorrect operation performed (71/431, 16.5%). Error distribution differed significantly (χ²=1325, P <0.01), with 947/1053 (89.9%) occurring outside the operating theatre. Surgical teams were responsible for 652/888 (73.4%) single-team errors and 109/116 (94%) multi-team errors; non-surgical teams were responsible for 235/888 (26.5%) single-team errors and 112/116 (96.6%) multi-team errors. Conclusions: NTEs associated with patient death predominantly occurred outside the operating theatre, arose from few recurrent behaviors, and involved surgical and non-surgical teams. Future NTS improvement strategies must extend beyond the theatre, be behaviorally informed, and target all teams involved.

Background Clinical practice guideline (CPG) development is a time- and resource-intensive process, yet their uptake may be limited by concerns among clinicians that guidelines could be used against them in malpractice cases. The role of CPGs in surgical litigation remains unclear. Aim To empirically evaluate how CPGs are used in surgical civil law and determine whether cited guidelines are surgery specific. Methods A systematic review of California Civil Trial Court Orders (Westlaw) was searched for surgery-related cases from 2021–2024. Case dockets were reviewed for guideline-based recommendations in expert testimony and in the Summary of Motion documents. Results A total of 192 cases were reviewed with eighty-three meeting inclusion criteria. CPGs were cited in three of eighty-three surgical malpractice cases (3.6 per cent), none of which were surgery specific. Conclusion CPGs appear to be rarely cited in surgical civil court cases and when referenced, they relate to non-surgical aspects of care. However, their violation may provide courts with decisive grounds for legal deliberation. Further studies evaluating a larger number of settlement cases using insurance company data would be invaluable to fully understand the role of surgical and non-surgical guidelines in shaping surgical medicolegal proceedings.

Background: Surgeons undertake diverse roles in clinical practice, administration, education, research and innovation. These responsibilities can give rise to conflicts of interest when personal, financial, or professional interests intersect with the fundamental obligations to patient care, research integrity, and ethical conduct. While conflicts of interest are inherent in modern surgical practice, inadequate recognition and management risk undermining ethical decision‐making and public confidence in the profession. Methods: A structured literature search was conducted using the Ovid MEDLINE database to identify relevant publications addressing conflicts of interest in surgical practice. Conflict of interest policies from surgical specialty colleges in Australia, Canada, Ireland, the United Kingdom, and the United States of America were also reviewed. Findings were synthesised narratively. Summary of Policies: Existing policies demonstrate broad consistency in defining conflicts of interest and emphasising disclosure. However, substantial variability exists in the depth of guidance for identifying, evaluating and managing conflicts. Empirical evidence highlights underreporting of conflicts of interest and associations between industry relationships and favourable research outcomes. Practical, context‐specific strategies for managing complex or evolving conflicts remain limited. Conclusions: Conflicts of interest are an inherent aspect of modern surgical practice. However, existing policies often lack practical, context‐specific guidance to address these conflicts. A structured process incorporating identification, disclosure, risk assessment, management, monitoring, and ongoing transparency and accountability should be adopted to uphold professional integrity, support ethical decision‐making, and maintain public trust within surgical practice.