The operative experience of present-day surgical residency training has evolved as a result of the contributions of laparoscopic surgery. Some traditional open procedures are now more descriptive and less of a familiarity to many general surgery residents (GSRs). The aim of this study was to investigate how open operative experience compares with laparoscopy for GSRs. A retrospective, multicenter, consecutive cohort study of all patients undergoing surgical intervention involving the appendix and gallbladder identified from the ACS-NSQIP database over a 2.5-year period. All GSR postgraduate year-level operative experience was recorded. Of 777 procedures, 13 laparoscopic appendectomy conversions to open (4.3%) by Rocky-Davis (15%) or lower midline (84.6%) incisions were performed versus 285 that remained laparoscopic (95.6%). Fifty (10.4%) open cholecystectomies (38 open + 10 conversions + 2 common bile duct (CBD) exploration), 27 (5.6%) laparoscopic cholecystectomies with cholangiogram, and 402 (83.9%) laparoscopic cholecystectomies were performed. Twenty-nine different GSRs participated in procedures. Eighty-five (10.9%) operations were performed with multi–postgraduate year levels. Surgical residents have an unequal operative experience for case-specific open procedures. A competency-based system to demonstrate a resident's hands-on surgical skills is fundamental to residency training and should be considered for specific types of low-volume open surgical cases.

International guidelines state that early laparoscopic cholecystectomy (ELC) is appropriate for all severity grades of acute cholecystitis and leads to reduced hospital stays and costs. A multicenter prospective randomized controlled trial recommends ELC over delayed laparoscopic cholecystectomy (DLC) management because in addition to reduced hospital stays and costs, ELC also leads to reduced patient morbidity. Therefore, ELC is standard of care for acute cholecystitis. We hypothesize that 1) international guidelines are not presently followed and that 2) a quality improvement (QI) project enforcing ELC for acute cholecystitis will increase rates of ELC management. A retrospective chart review of all surgical consults for cholecystitis from January 2016 to December 2018 was undertaken. A total of 307 patients diagnosed with acute cholecystitis were included. ELC was defined as cholecystectomy within hospital admission. Pre-QI ELC versus DLC rates were 77.4 per cent (233/301) versus 22.6 per cent (68/301). Eight DLC patients (11.8%) returned to the ED after discharge secondary to persistent signs and symptoms of cholecystitis and 62.5 per cent (5/8) received an immediate cholecystectomy before their elective surgery date. After QI initiatives, ELC rates rose to 100 per cent (6/6). These data show there was a lack of consistent ELC management of acute cholecystitis.

Necrotizing infections are rapidly spreading progressive infections with necrosis of the subcutaneous tissue that can have severe complications. We report a case of right breast necrotizing mastitis in a 40-year-old postpartum woman who presented in septic shock. The patient was resuscitated with intravenous fluids and broad-spectrum antibiotics, followed by urgent surgical debridement. We discuss the patient's presentation, our treatment approach, and outcomes, with a brief review of the literature. We conclude that necrotizing breast infections are rare, but must be known to obstetricians and breast and surgical oncologists, because without urgent treatment and surgical debridement, the mortality risk is high. K E Y W O R D Snecrotizing infection of breast, surgical debridement