Gabriela Ghitulescu

Proving the value of simulation in laparoscopic surgery

Objective:To assess the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) physical laparoscopic simulator for construct and predictive validity and for its educational utility. Summary Background Data:MISTELS is the physical simulator incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in their Fundamentals of Laparoscopic Surgery (FLS) program. MISTELS’ metrics have been shown to have high interrater and test-retest reliability and to correlate with skill in animal surgery. Methods:Over 200 surgeons and trainees from 5 countries were assessed using MISTELS in a series of experiments to assess the validity of the system and to evaluate whether practicing MISTELS basic skills (transferring) would result in skill acquisition transferable to complex laparoscopic tasks (suturing). Results:Face validity was confirmed through questioning 44 experienced laparoscopic surgeons using global rating scales. MISTELS scores increased progressively with increasing laparoscopic experience (n = 215, P < 0.0001), and residents followed over time improved their scores (n = 24, P < 0.0001), evidence of construct validity. Results in the host institution did not differ from 5 beta sites (n = 215, external validity). MISTELS scores correlated with a highly reliable validated intraoperative rating of technical skill during laparoscopic cholecystectomy (n = 19, r = 0.81, P < 0.0004; concurrent validity). Novice laparoscopists were randomized to practice/no practice of the transfer drill for 4 weeks. Improvement in intracorporeal suturing skill was significantly related to practice but not to baseline ability, career goals, or gender (P < 0.001). Conclusion:MISTELS is a practical and inexpensive inanimate system developed to teach and measure technical skills in laparoscopy. This system is reliable, valid, and a useful educational tool.

Evaluating laparoscopic skills

Background: The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) was developed to assess laparoscopic skills and to score them objectively. This system has been described previously. The purpose of the current study was to determine a pass/fail threshold. Methods: In this study. 165 individuals were tested and grouped according to their clinical competency in laparoscopic surgery. The noncompetent group consisted of medical students and surgical residents in their first 2 years of training (n = 83). The competent group consisted of chief general surgical residents in their last year of training, laparoscopy fellows. and practicing laparoscopic surgeons (n = 82). The Mann-Whitney U test was used to evaluate differences in task performance between the two groups. Results: There was a significant difference in total scores and individual MISTELS task scores between the noncompetent and competent laparoscopic surgeons (189 vs 372.5; p < 0.0001). By setting specific pass/fail total score thresholds (cutoff scores), competent surgeons can be discriminated from noncompetent surgeons. Conclusion: An objective pass/fail evaluation can be given to individuals tested with the MISTELS system.

Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? Acs-nsqip Analysis by Coarsened Exact Matching

BACKGROUND: Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE: The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN: This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS: Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS: A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45–0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34–0.97), ileus (OR, 0.79; 95% CI, 0.59–0.98), and major morbidity (OR, 0.73; 95% CI, 0.55–0.96), but not mortality (OR, 0.32; 95% CI, 0.08–1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS: This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS: Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.

Knowing the operative game plan: a novel tool for the assessment of surgical procedural knowledge

BACKGROUND What is the source of inadequate performance in the operating room? Is it a lack of technical skills, poor judgment or a lack of procedural knowledge? We created a surgical procedural knowledge (SPK) assessment tool and evaluated its use. METHODS We interviewed medical students, residents and training program staff on SPK assessment tools developed for 3 different common general surgery procedures: inguinal hernia repair with mesh in men, laparoscopic cholecystectomy and right hemicolectomy. The tools were developed as a step-wise assessment of specific surgical procedures based on techniques described in a current surgical text. We compared novice (medical student to postgraduate year [PGY]-2) and expert group (PGY-3 to program staff) scores using the Mann-Whitney U test. We calculated the total SPK score and defined a cut-off score using receiver operating characteristic analysis. RESULTS In all, 5 participants in 7 different training groups (n = 35) underwent an interview. Median scores for each procedure and overall SPK scores increased with experience. The median SPK for novices was 54.9 (95% confidence interval [CI] 21.6-58.8) compared with 98.05 (95% CP 94.1-100.0) for experts (p = 0.012). The SPK cut-off score of 93.1 discriminates between novice and expert surgeons. CONCLUSION Surgical procedural knowledge can reliably be assessed using our SPK assessment tool. It can discriminate between novice and expert surgeons for common general surgical procedures. Future studies are planned to evaluate its use for more complex procedures.

Cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Objective: To compare the cost-effectiveness of early laparoscopic choleystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. Design: A decision-tree model was developed using a series that modelled all potential outcomes for both treatment options. Probabilities were estimated from a Cochrane review. Costs were based on the UK National Schedule of Reference Costs for the year 2006. Setting: UK National Health Service. Patients: Patients with acute cholecystitis. Intervention: Either ELC or DLC with a time frame of 1 year. Main outcome: Outcomes were measured in quality-adjusted life years (QALY) gained over 1 year. Results: Early laparoscopic choleystectomy is less costly and results in better quality of life (+0.05 QALY per patient) than DLC. Given a willingness-to-pay threshold of £20 000 per QALY gained, there is a 70.9% probability that ELC is more cost-effective than DLC. Conclusion: On average, ELC is less expensive and results in better quality of life than DLC.