Benjie Tang

Minimal access surgery (MAS)-related surgeon morbidity syndromes

The benefits of minimal access surgery (MAS) in terms of accelerated recovery, reduced period of short-term disability, and patient outcome account for the widespread use of the laparoscopic approach by the majority of general surgeons. In adopting this approach with its current limitations and poor ergonomics, surgeons have been known to sustain surgery-related injuries encompassed by a spectrum best described as MAS-related surgeon morbidity syndromes, some of which are currently overlooked and poorly researched. Equivalent morbidities including the overuse syndrome (from overuse of certain muscle groups during long operations) have been documented in open surgery but are nowadays rare occurrences. As more advanced MAS operations are performed with long execution times, new patterns of neuromusculoskeletal injuries are being recognized. The surgical fatigue syndrome has also been described, though its complex nature is not fully understood. Virtually little is known on other long-term adverse effects on the surgeon following many years of operating from images displayed on a television monitor or LCD screen, and these include deterioration of visual acuity and function of the ocular muscles responsible for fixation–refixation of the eyeballs. The limited reported literature on the MAS-related surgeon morbidity syndromes identifies certain risk factors for these injuries pertaining to central and peripheral domains. Only improved knowledge of the etiology and underlying ergonomic factors based on investigative studies followed by improved instrumentation and operating room (OR) ergonomics will provide near- and long-term solutions.

Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome.

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

BackgroundThere is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees’ operative and cognitive skills during laparoscopic training courses.MethodsPerformance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA.ResultsThe study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = −0.864 and r = −0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001).ConclusionsOCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

A Qualitative Assessment of Human Cadavers Embalmed by Thiel's Method Used in Laparoscopic Training for Renal Resection.

Human cadaveric tissue is the fundamental substrate for basic anatomic and surgical skills training. A qualitative assessment of the use of human cadavers preserved by Thiels method for a British Association of Urological Surgeons—approved, advanced laparoscopic renal resection skills training course is described in the present study. Four trainees and four experienced laparoscopic surgeons participated in the course. All participants completed a five‐point Likert scale satisfaction questionnaire after their training sessions. The quality of cadaveric tissue and the training session were assessed with particular emphasis placed on the ease of patient positioning, the ease of trocar placement, the preservation of tissue planes, the ease of renal pedicle dissection, and the quality of tissue preservation. All of the participants highly rated the quality of the cadaveric tissue embalmed by Thiels method (mean scores for quality on the five‐point Likert scale were 4.5 and 4.3 by the trainees and experienced laparoscopic surgeons, respectively). All of the steps of laparoscopic renal resection were rated 4.0 or more on the Likert scale by both trainees and faculty members. The initial response rates for using a human cadaver embalmed by Thiels method as a training tool for laparoscopic nephrectomy showed encouraging results. The performance of a laparoscopic nephrectomy on a human cadaver embalmed by Thiels method bears close resemblance to real laparoscopic nephrectomy procedures, and thus demonstrates added advantages to the previously reported models.

Human reliability analysis (HRA) techniques and observational clinical HRA.

Abstract This review explains the nature of human reliability analysis (HRA) methods developed and used for predicting safety in high-risk human activities. HRA techniques have evolved over the years and have become less subjective as a result of inclusion of (i) cognitive factors in the man-machine interface and (ii) high and low dependency levels between human failure events (HFEs). All however remain probabilistic in the assessment of safety. In the translation of these techniques, developed for assessment of safety of high-risk industries (nuclear, aerospace etc.) where catastrophic failures from the man-machine complex interface are fortunately rare, to the clinical operative surgery (with its high incidence of human errors), the system loses subjectivity since the documentation of HFEs can be assessed and studied prospectively on the basis of an objective data capture of errors enacted during a defined clinical activity. The observational clinical-HRA (OC-HRA) was developed specifically for this purpose, initially for laparoscopic general surgery. It has however been used by other surgical specialties. OC-HRA has the additional merit of objective determination of the proficiency of a surgeon in executing specific interventions and is adaptable to the evaluation of safety and proficiency in clinical activities within the preoperative and postoperative periods.

Development and use of a restructured animal tissue model for training in laparoscopic salpingostomy and salpingectomy.

Ectopic pregnancy is commonly managed via either laparoscopic salpingostomy or salpingectomy. However, there is a proficiency gain curve in mastering these 2 surgical procedures, and an effective simulated model is essential for training students of gynecology. The objective of this study was to develop and evaluate a restructured animal tissue model that can be used in the surgical training of gynecologists in laparoscopic salpingostomy and salpingectomy. Since 2005, a hands-on laparoscopic training course for gynecologic students has been developed and conducted at the Cushieri Skills Centre, University of Dundee. A restructured animal tissue model of ectopic pregnancy was developed and used for practicing laparoscopic salpingostomy and salpingectomy. At the end of each course, data were collected using a standardized anonymous questionnaire using a Likert scale (1= strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; and 5 = strongly agree). Feedback on the ectopic pregnancy model from course participants was obtained insofar as the realism of the anatomical condition of the model, quality of the tissue and organ color, quality of organ consistency, and operative tactile properties during dissection. Over the last 6 years, from June 2005 to September 2010, 96 gynecologic trainees have practiced using this phantom. The mean (SD) overall satisfaction rate for the training phantom for laparoscopic salpingostomy and salpingectomy was 4.9 (0.1) on a scale of 1(unrealistic/poor) to 5 (very realistic/useful). Compared with real operating conditions, quality assessment of the model for anatomical condition was 4.9 (0.2), for quality of tissue and organ color was 4.9 (0.4), for organ consistency was 4.8 (0.3), and for operative tactility was 4.8 (0.6). It was concluded that the restructured animal tissue model of laparoscopic salpingostomy and salpingectomy in ectopic pregnancy is realistic, cost-effective, and simple enough to be produced for use in laboratory-based surgical training courses.

The effect of a simple intraprocedural checklist on the task performance of laparoscopic novices

BACKGROUND Surgical checklists are used for error reduction. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to study the effect of a self-administered checklist on the laparoscopic task performance of novices during a standardized task. METHODS Twenty novices were randomized into 2 equal groups, those receiving paper feedback (control group) and those receiving paper feedback and the checklist (checklist group). Subjects performed laparoscopic double knots, repeated over 5 separate stages. Human reliability assessment technique was used for error analysis. RESULTS 2,341 errors were detected during the 5 stages. During the first stage, the errors were not significantly different between the 2 groups. The checklist group committed significantly fewer errors as compared with the control group during all the later 4 stages (P < .01). CONCLUSIONS The simple intraprocedural checklist significantly improved the laparoscopic task performance and the learning curve of laparoscopic novices.

Videotaping of surgical procedures and outcomes following extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer

Video‐recording of emerging minimally invasive surgical procedures is likely to become an integral component of patient record‐keeping in the future for prostate cancer treatment. No prior work has shown the impact of videotaping of laparoscopic prostatectomy on patient outcomes. Our aim was to determine correlation between independent peer review of videotaping quality scores of extraperitoneal laparoscopic prostatectomy (ELRP) with complications, re‐admissions, functional, and early oncological outcomes.

Effect of mental training on short-term psychomotor skill acquisition in laparoscopic surgery - a pilot study

Aim: The mental demands of laparoscopic surgery create a steep learning curve for surgical trainees. Experienced surgeons informally conduct mental training prior to starting a complex laparoscopic procedure. Reconstructing haptic feedback to mentally observe surgeon-instrument-tissue interaction is considered to be acquired only with experience. An experiment was devised to implement mental training for the haptic feedback reconstruction and its effect on laparoscopic task performance was observed. Methods: Twenty laparoscopy novice medical students with normal/corrected visual acuity and normal hearing were randomised into two groups. Both groups were asked to apply a pre-established consistent force by means of retracting a laparoscopic grasper fixed to an electronic weight scale. Studied group underwent mental training while control group conducted a laparoscopic task as a distraction exercise. Accuracy of the task performance was measured as primary outcome. Performance between dominant and non-dominant hands was the secondary outcome. Results: Baseline assessment of both dominant and non-dominant hands between groups were similar (P > 0.05). Mental training group improved their performance (0.66 ± 0.04) vs . (1.06 ± 0.14) with dominant hand (P < 0.01) and (0.73 ± 0.04) vs . (1.10 ± 0.20) with non-dominant hand (P < 0.05), when compared with control group. Conclusion: In a laparoscopic task performance, skill transfer is significantly accurate if mental haptic feedback reconstruction is achieved through mental training.

Development and Validation of a Novel and Cost-Effective Animal Tissue Model for Training Transurethral Resection of the Prostate

OBJECTIVES To develop and validate a new and cost-effective animal tissue training model for practicing resection skills of transurethral resection of the prostate (TURP). METHODS AND MATERIALS A porcine kidney was prepared and restructured to simulate the relevant anatomy of the human prostate. The restructured prostate was connected to an artificial urethra and bladder. Face, content, and construct validity of the model was carried out using a 5-point Likert scale questionnaire, and comparison in task performance between participants and experts was made using observational clinical human reliability analysis. RESULTS A total of 24 participants and 11 experts who practiced TURP skills on this model from October 2014 to December 2015 were recruited. The mean score on specific feature of the anatomy and color, sensation of texture and feeling of resection, conductibility of current, and efficacy and safety of the model were 4.34 ± 0.37, 4.51 ± 0.63, 4.13 ± 0.53, and 4.35 ± 0.71, respectively, by participants whereas they were 4.22 ± 0.23, 4.30 ± 0.48, 4.11 ± 0.62, and 4.56 ± 0.77, respectively, by the experts on a scale of 1 (unrealistic) to 5 (very realistic). Participants committed more technical errors than the experts (11 vs 7, p < 0.001), produced more movements of the instruments (51 vs 33, p < 0.001), and required longer operating time (11.4 vs 6.2min, p < 0.001). CONCLUSIONS A newly developed restructured animal tissue model for training TURP was reported. Validation study on the model demonstrates that this is a very realistic and effective model for skills training of TURP. Trainees committed more technical errors, more unproductive movements, and required longer operating time.