Avril Chang

Systems Approaches to Surgical Quality and Safety: From Concept to Measurement

Objective:This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. Summary Background Data:Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patients stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. Methods:Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an “operation profile” to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.

Practice distribution in procedural skills training: a randomized controlled trial.

Background“Massed” and “distributed” practice are important concepts in the acquisition of fine motor skills, and may be important in training in procedural skills.MethodsA total of 41 novice subjects were recruited and randomized to three groups to receive training on the MIST VR surgical trainer. There were 14 subjects in each of groups A and B and 13 subjects in group C. Training comprised 20 min of massed practice for group A, 20 min of distributed practice in 5 min blocks for group B, and 15 min of distributed practice in 5-min blocks for group C. Following the training period, all groups had a 5-min rest period, followed by a 5-min retention test. Comparisons were made between groups A and B, and groups A and C.ResultsThere was a statistically significant difference between groups A and B (p= 0.023) on the retention test, with group B performing better. The increment between the groups was 19% for the overall score on MIST VR. There were also significant differences in the time taken to complete the task during the training phase (p=0.023, training blocks 3 and 4). Graphical representation suggests no effect between groups A and C, and statistical analysis confirms that the observed difference in median score is not significant.ConclusionThis study demonstrates a benefit for distributed practice over massed practice in learning laparoscopic surgical skills on the MIST VR surgical trainer. This finding has potential implications for skills training in all areas of medicine.

Bimodal assessment of laparoscopic suturing skills: construct and concurrent validity.

BackgroundThe assessment of technical skills should provide objective feedback and judge suitability of progress during training. The aim of this study was to validate two objective assessment techniques for laparoscopic suturing and demonstrate a correlation between them.MethodsSix experts, seven surgeons skilled in laparoscopic suturing, and 13 with no laparoscopic suturing skills were asked to place two or three intracorporeal sutures on a synthetic suture pad. The latter group was given video-based instructions prior to the execution of the sutures. Ergonomic conditions were standardized for all subjects. The procedures were recorded on videotape and two blinded observers rated the first suture of each subject on a 29-point checklist. A motion analysis system, Imperial College Surgical Assessment Device, was used to assess psychomotor skills.ResultsThere was a significant difference in the time taken (p = 0.000) and total path length (p = 0.000) per suture across the groups. There were also a significant difference in the total checklist score (p = 0.000) and its individual categories. The was a strong correlation between the total path length and the total checklist score (coefficient, 0.78; p < 0.001).ConclusionsA combination of the motion analysis system and the checklist would make the process of formative feedback during the learning of intracorporeal suturing objective and comprehensive.

Functional results two years after laparoscopic rectopexy

BACKGROUND Rectopexy is one of the accepted treatment options for full-thickness rectal prolapse, but the details of the technique remain controversial. This unit has adopted a laparoscopic approach as an alternative to open surgery, and has used three techniques: mesh, suture, and resection. This retrospective study compares the long-term outcome. METHODS From 1993 to 1995, 14 patients underwent a laparoscopic posterior mesh rectopexy. From 1996 to 1999, 34 patients underwent laparoscopic suture rectopexy with (n = 18) or without sigmoid resection (n = 16). RESULTS There was no postoperative mortality, and morbidity was similar in the three groups, ranging from 11 to 19%. The mean follow-up was 47, 24, and 20 months for mesh, suture, and resection rectopexy, respectively. During follow-up, 1 patient in each group developed mucosal prolapse. There was no difference between the three groups for incontinence rate, which improved in more than 75% of patients who had impaired continence preoperatively. Postoperative constipation was observed in 2 patients (11%) after resection rectopexy, in 10 (62%) after suture rectopexy (P < 0.01 versus resection), and in 9 (64%) after mesh rectopexy (P < 0.01 versus resection). CONCLUSIONS Our results show that the addition of sigmoid resection to laparoscopic rectopexy is safe and could contribute to reduce the risk of severe constipation after operation. Laparoscopic mesh rectopexy confers no advantage over the sutured technique, which we now use as our fixation method of choice.

Validity and reliability of a virtual reality upper gastrointestinal simulator and cross validation using structured assessment of individual performance with video playback.

Background: This study aims to evaluate the ability of an upper gastrointestinal virtual reality simulator to assess skills in endoscopy, and to validate its metrics using a video-endoscopic (VES) technique. Methods: The 32 participants in this study were requested to undertake two cases on the simulator (Simbionix, Israel). Each module was repeated twice. The simulator’s metrics of performance were used for analysis. Two blinded observers rated performance watching the simulator’s playback feature. Results: There were 11 novices (group 1), 11 trainees with intermediate experience (10–50 procedures, group 2), and 10 experienced endoscopists (>200 procedures, group 3). There was a significant difference in the total time required to perform the procedure (p < 0.001), percentage of mucosa visualized (p < 0.001), percentage of pathologies visualized (p < 0.001), and number of inappropriate retroflexions (p = 0.015) across the three groups. The reliability of assessment on the simulator was greater than 0.80 for all parameters. The VES assessment also was able to discriminate performance across the groups (p < 0.001). There was a significant correlation between the VES score and the percentage of mucosa visualized (rho = 0.60; p < 0.001). Conclusions: The upper gastrointestinal simulator may be a useful tool for determining whether a trainee has achieved a desired level of competence in endoscopy. The next step will be to validate the VES score in real procedures.

Multiple Objective Measures of Skill (moms): A New Approach to the Assessment of Technical Ability in Surgical Trainees

Objective The assessment of surgical technical skills has become an important topic in recent years. This study presents the validation of a 6-task skills examination for junior surgical trainees (at the level of the Membership of the Royal College of Surgeons). Summary Background Data Six tasks were evaluated in a project that also examined the feasibility of this method of assessment. The tasks were knowledge of sutures and instruments; knowledge of surgical devices; knot formation; skin-pad suturing, closure of an enterotomy; excision of a skin lesion; and laparoscopic manipulation. Comparisons were made between a group of junior trainees (n = 13), and a group of seniors (n = 8). Results Each of the 6 tasks was able to be used to discriminate between the 2 groups. In all, there were 19 primary analyses across the 6 tasks, and 17 of these showed significant differences between the groups (P values ranging from 0.037 to < 0.001). There was generally a strong correlation between the analyses, and when a mean rank was calculated, the difference between groups was significant (P = 0.005 on Mann–Whitney U test; mean ranks 13.9 and 6.3 [of 21], for juniors and seniors respectively). Reliability of the 6-task assessment was very good at 0.70 (Cronbachs Alpha). Conclusions A skills examination is a feasible and effective method of assessing the technical ability of basic surgical trainees.

Self-appraisal hierarchical task analysis of laparoscopic surgery performed by expert surgeons

BackgroundEvaluation of technical skill is notoriously difficult because of the subjectivity and time-consuming expert analysis. No ongoing evaluation scheme exists to assess the continuing competency of surgeons. This study examined whether surgeons’ self-assessment accurately reflects their actual surgical technique.MethodsHierarchical task analysis (HTA) of laparoscopic cholecystectomy was constructed. Ten expert surgeons were asked to modify the HTA for their own technique. The HTAs of these surgeons then were compared with their actual operations, which had been recorded and assessed by two observers.ResultsA total of 40 operations were assessed. All the gallbladders subjected to surgery were classified as grades 1 to 3. The mean interrater reliability for the two observers had a k value of 0.84 (p < 0.05), and the mean intrarater reliability between surgeons and observers had a k value of 0.79 (p < 0.05).ConclusionsSurgeons’ self-evaluation is accurate for technical skills aspects of their operations. This study demonstrates that self-appraisal using HTA is feasible, accurate, and practical. The authors aim to increase the numbers in their study and also to recruit residents.

A nontransfusional perioperative management regimen for patients with sickle cell disease undergoing laparoscopic cholecystectomy.

BackgroundPatients with sickle cell disease (SCD) are at increased risk for cholelithiasis. Laparoscopic cholecystectomy is the most frequent general surgical operation performed for this group of patients. Acute chest syndrome (ACS) is the most common cause of postoperative death among SCD patients. This study aimed to evaluate the impact of a novel perioperative management regimen involving prophylactic continuous positive airways pressure (CPAP) ventilation and avoidance of preoperative blood transfusion on postoperative SCD-related complications after laparoscopic cholecystectomy.MethodsA retrospective study included all SCD patients who underwent laparoscopic cholecystectomy since 1997 at our institution. Medical notes were analyzed to assess the rates of postoperative complications in relation to the severity of SCD.ResultsA total of 13 patients were identified. There were no recorded episodes of acute painful crises and only one patient experienced an episode of ACS requiring protracted CPAP.ConclusionLaparoscopic cholecystectomy can be safely performed for SCD patients without prior blood transfusion. A defined perioperative regimen including the use of routine postoperative prophylactic CPAP for these patients helps to reduce SCD-related postoperative complications such as ACS and painful vaso-occlusive crises.

Technical skills errors in laparoscopic cholecystectomy by expert surgeons

Background:Performing laparoscopic surgery involves a complex cascade of cognitive skills, which may inherently have a constant technical error rate. We assess generic and specific minor and major error rates in laparoscopic cholecystectomies (LCs) performed by consultant surgeons.Methods:Checklists of generic (11) and specific technical minor (six) and major events (eight) were devised for LCs. Two experienced surgeons assessed each full-length operation blindly and independently.Results:A total of 37 LCs were performed by eight consultants. There were no major intraoperative or postoperative complications. Mean inter-rater reliability was κ = 0.91 (range 0.80–0.98) for each of the error categories. Error rates were generic (27/407) 6.6%, minor (59/222) 26.6%, and major (8/296) 2.7%, respectively. There was a significant statistical difference between the minor error group and the other groups, p ≤ 0.05.Conclusions:Performing laparoscopic surgery may always have a background technical error rate. Our present study demonstrates a migration of surgical technical errors in expert laparoscopic surgeons. The surgeons migrate technically when they execute a high rate of procedure-specific minor errors. However, when it comes to the major fundamental aspects of the operation, they dynamically adapt and migrate away from performing major technical errors. We aim to continue the study to increase cases, assess trainees as well, and also explore other factors that may affect the surgeon when executing surgical technical tasks.

Bimodal assessment of laparoscopic suturing skills

BackgroundThe assessment of technical skills should provide objective feedback and judge suitability of progress during training. The aim of this study was to validate two objective assessment techniques for laparoscopic suturing and demonstrate a correlation between them.MethodsSix experts, seven surgeons skilled in laparoscopic suturing, and 13 with no laparoscopic suturing skills were asked to place two or three intracorporeal sutures on a synthetic suture pad. The latter group was given video-based instructions prior to the execution of the sutures. Ergonomic conditions were standardized for all subjects. The procedures were recorded on videotape and two blinded observers rated the first suture of each subject on a 29-point checklist. A motion analysis system, Imperial College Surgical Assessment Device, was used to assess psychomotor skills.ResultsThere was a significant difference in the time taken (p=0.000) and total path length (p=0.000) per suture across the groups. There were also a significant difference in the total checklist score (p=0.000) and its individual categories. The was a strong correlation between the total path length and the total checklist score (coefficient, 0.78;p<0.001).ConclusionsA combination of the motion analysis system and the checklist would make the process of formative feedback during the learning of intracorporeal suturing objective and comprehensive.