Iman Ghaderi

Performance of simulated laparoscopic incisional hernia repair correlates with operating room performance.

BACKGROUND the role of simulation for training in procedures such as laparoscopic incisional hernia repair (LIHR) is unknown. The purpose of this study was to determine whether performance in simulated LIHR correlates with operating room (OR) performance. METHODS subjects performed LIHR in the University of Maryland Surgical Abdominal Wall (SAW) simulator and the OR. Trained observers used a LIHR-specific global rating scale (Global Operative Assessment of Laparoscopic Skills-Incisional Hernia) to assess performance. Global Operative Assessment of Laparoscopic Skills-Incisional Hernia includes 7 domains (trocar placement, adhesiolysis, mesh sizing, mesh positioning, mesh fixation, knowledge and autonomy in instrument use, and overall competence). The correlation between simulator and OR performance was assessed using the Pearson coefficient. RESULTS fourteen surgeons from 2 surgical departments participated. Experienced surgeons (n = 9) were defined as attending surgeons and minimally invasive surgury (MIS) fellows, and novice surgeons (n = 5) were general surgery residents (postgraduate years 3-5). The correlation between performance in the OR and the simulator for the entire group was .87 (95% confidence interval, .63-.96; P < .001). CONCLUSIONS there was an excellent correlation between LIHR performance in the simulator and clinical LIHR. This suggests that performance in the SAW simulator may predict performance in the operating room.

Surgical Abdominal Wall (SAW): A Novel Simulator for Training in Ventral Hernia Repair

Laparoscopic ventral hernia repair (LVHR) is a relatively common procedure that requires advanced minimally invasive surgical skills to perform. The role for simulation is increasingly supported as an effective way to teach surgical skills and accelerate the learning curve. This article describes The University of Maryland’s Surgical Abdominal Wall, an inexpensive procedure-specific physical simulator for LVHR, and summarizes the authors’ early experiences using this model in a curriculum for surgery residents.

GOALS-Incisional Hernia: A Valid Assessment of Simulated Laparoscopic Incisional Hernia Repair

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution

BACKGROUND Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH. MATERIALS AND METHODS Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively. RESULTS Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic. CONCLUSIONS This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks

BACKGROUND Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks. METHODS 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks. RESULTS Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks. CONCLUSIONS Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development.

Canadian general surgeons' opinions about clinical practice audit

BACKGROUND The objective of this study was to explore the opinions of Canadian surgeons about their knowledge regarding clinical practice audit (CPA), existing audit tools, experience with CPA, barriers to implementation, and concerns about consequences of CPA implementation. METHODS A 20-question survey was distributed to members of the Canadian Association of General Surgeons. RESULTS Of the surveys distributed, 108 were completed, a response rate of 13.5%. The mean age of the participants was 44 years (SD, 12). Familiarity with common audit tools ranged from 4% to 28%, with 41% familiar with none and 44% having previously performed CPA. Most respondents believed that CPA should be mandatory (48%); that CPA is best done by self (34%); and that the Ministry of Health ought to pay for CPA (35%). Using a Likert scale, we found that a majority of respondents felt that CPA is effective in changing both clinical practice (73%) and patient outcomes (57%) and that barriers included time constraints (91%), cost (62%), resources (91%), and inadequate documentation (57%). A majority of respondents would participate in CPA if the data were reviewed by themselves (93%), their department (82%), the Royal College (51%), or provincial organizations (48%) as long as the data were not made available to the public (42%), the ministry of health (48%), or hospital administration (47%). CONCLUSION Canadian surgeons perceive usefulness in clinical audit but have limited knowledge about available audit tools and resources. The creation of a national auditing system combined with strategies for effective implementation of this system is the stepping-stone in this process.

Duplicated gallbladder with obstructive jaundice: a case report with video

A 38-year-old male presented with painful obstructive jaundice. Ultrasound showed biliary dilatation and a duplicated gallbladder (DG). Magnetic resonance cholangiopancreatography (MRCP) imaging confirmed the diagnosis of DG and raised the suspicion of a stricture in the distal common bile duct. Endoscopic retrograde cholangiogram, sphincterotomy with small stone extraction, and biliary stent placement were accomplished, and the patient was transferred to our tertiary center. Given the report of a stricture, endoscopic retrograde cholangiopancreatography (ERCP) was repeated and showed no duct narrowing or persistent choledocholithiasis, but only one cystic duct and gallbladder filled. The patient subsequently underwent laparoscopic cholecystectomy using top-down technique with complete resection of both gallbladders. Postoperatively, the patient underwent another ERCP for elevated bilirubin due ampullary edema. Subsequently, his bilirubin normalized and he was discharged home on postoperative day 5. DG is a rare anatomical finding that may be associated with choledocholithiasis and cholecystitis. In this case, a combination of radiographic, endoscopic and laparoscopic procedures was utilized to resolve the patient’s clinical problem.

SAGES framework for Continuing Professional Development (CPD) courses for practicing surgeons: the new SAGES course endorsement system

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) recognizes that the discipline of surgery is dynamic and continues to evolve. Modifications of standard surgical procedures and completely new procedures are usually introduced gradually into clinical practice, a process that may require special training or privileges. Additional training will often be required to integrate techniques or procedures that are new to the individual surgeon. The same is also true for procedures that represent a substantial change in existing methods or practices or that require familiarity with new technology [1–5]. The purpose of this document is to provide guidelines for course directors who plan to design educational activities for Continuing Professional Development (CPD) of practicing surgeons. Additionally, it provides guidance regarding requirements for SAGES endorsement of such courses.