Karim Qayumi

Correlating motor performance with surgical error in laparoscopic cholecystectomy

BackgroundAnalysis of motor performance in minimally invasive surgery (MIS) is a new field with applications in surgical training, surgical simulators, and robotics. Force/torque and derivatives of tool tip position (velocity, acceleration, and jerk) are examples of measures of motor performance (MMPs). Few studies have measured MMPs or have correlated MMPs with surgical performance during MIS on humans. The objectives of this study were to determine the feasibility of a novel multimodal system to quantify MMPs in laparoscopic cholecystectomy and to attempt to correlate MMPs with the magnitude of error as a measure of surgical performance.MethodsNovice and expert surgeons performed laparoscopic cholecystectomies in two groups of three patients each. MMPs were obtained using a combination of optical and electromagnetic tool tip tracking and a force/torque sensor on a modified Maryland dissector. Error scores for laparoscopic cholecystectomy were calculated using a previously validated system. Novice and expert measurements were compared, and correlations were made between error scores and MMPs.ResultsError scores were similar between novices and experts. Novice surgeons had a significantly greater mean velocity (566 ± 83 vs 85 ± 32 mm/s, p = 0.006) and acceleration (2,600 ± 760 vs 440 ± 174 mm/s2, p = 0.050) compared to expert surgeons. Force (16.5 ± 4.6 vs 18.3 ± 6.0 N, p = 0.829), position (121 ± 25 vs 135 ± 72 mm, p = 0.863), and jerk (19,600 ± 7,410 vs 2,430 ± 367 mm/s3, p = 0.138) were similar between groups. A positive correlation was found in novice surgeons between error score and jerk (Pearson correlation, 0.999; p = 0.035).ConclusionsIt is feasible to quantify MMPs in laparoscopic cholecystectomy. Novice and expert surgeons can be differentiated by MMPs; moreover, there may be a positive correlation between jerk and error score in novice surgeons.

Liver bridging techniques in the treatment of acute liver failure.

The introduction of orthotopic liver transplantation in the management of acute liver failure has dramatically increased the survival rates of patients at the cost of removing the patients native liver and life-long dependence on immunosuppression. However, it is well known that in many patients with acute liver failure the diseased liver has the potential to recover. Death in these patients is often due to increased intra-cranial pressure or infection. Liver bridging techniques are assigned to temporarily provide liver function and enable the native liver to recover in patients with acute liver failure. They represent an attractive alternative to conventional liver transplantation in the management of acute liver failure, since after recovery of the native liver the patient is freed from immuno-suppression with all associated side-effects and risks. Auxiliary liver transplantation, artificial liver support devices and hepatocyte transplantation represent different ways of bridging liver function in acute liver failure. The aim of this review is to present the ideas and principles of these three different liver bridging techniques. We will discuss the relative importance and the future potential of theses bridging techniques in the treatment of acute liver failure by comparing the experimental and clinical results.The introduction of orthotopic liver transplantation in the management of acute liver failure has dramatically increased the survival rates of patients at the cost of removing the patients native liver and life-long dependence on immunosuppression. However, it is well known that in many patients with acute liver failure the diseased liver has the potential to recover. Death in these patients is often due to increased intra-cranial pressure or infection. Liver bridging techniques are assigned to temporarily provide liver function and enable the native liver to recover in patients with acute liver failure. They represent an attractive alternative to conventional liver transplantation in the management of acute liver failure, since after recovery of the native liver the patient is freed from immuno-suppression with all associated side-effects and risks. Auxiliary liver transplantation, artificial liver support devices and hepatocyte transplantation represent different ways of bridging liver function in acute liver failure. The aim of this review is to present the ideas and principles of these three different liver bridging techniques. We will discuss the relative importance and the future potential of theses bridging techniques in the treatment of acute liver failure by comparing the experimental and clinical results.

Surgical management of dyslipidemia: clinical and experimental evidence.

Coronary artery disease (CAD) is still a major cause of mortality in developed countries, and dyslipidemia is one of its major causes. In an attempt to reduce both mortality and morbidity from CAD, several dietary, pharmacological, and surgical approaches have been used to reduce plasma cholesterol levels. In this brief review, we summarize the evidence for cholesterol-lowering effects and safety of partial ileal bypass (PIB) procedure in both human and animal studies. The results of the Program on the Surgical Control of the Hyperlipidemias (POSCH), which involved a total of 838 subjects with myocardial infarction, are promising. A 5-year follow-up of this study revealed significant reductions of up to 27% in total cholesterol (TC) and up to 42% in low-density lipoprotein (LDL) cholesterol levels along with an increase of up to 8% in high-density lipoprotein (HDL) cholesterol levels as compared to controls. These changes were associated with other benefits such as increased HDL/TC and HDL/LDL ratios, and a significant decrease in apolipoprotein (apo) B100 and increase in apo AI levels. Similar results were also demonstrated by other studies. PIB surgery is one of the most effective methods for reduction of plasma cholesterol levels, particularly in patients with heterozygous familial hypercholesterolemia. This procedure is also applicable to treatment of sitosterolemia, a rare genetic disorder in which the absorption of plant sterols is abnormally high. Although no major complications of this method have been reported, more extensive studies are required to evaluate its long-term effects on renal and hepatic function. Similarly, long-term impact of this procedure on progression/regression of atherosclerotic lesions must be documented. Finally, indications for this procedure should be carefully considered, particularly in view of availability of other treatments of dyslipidemia.

Status of simulation in health care education: an international survey.

Simulation is rapidly penetrating the terrain of health care education and has gained growing acceptance as an educational method and patient safety tool. Despite this, the state of simulation in health care education has not yet been evaluated on a global scale. In this project, we studied the global status of simulation in health care education by determining the degree of financial support, infrastructure, manpower, information technology capabilities, engagement of groups of learners, and research and scholarly activities, as well as the barriers, strengths, opportunities for growth, and other aspects of simulation in health care education. We utilized a two-stage process, including an online survey and a site visit that included interviews and debriefings. Forty-two simulation centers worldwide participated in this study, the results of which show that despite enormous interest and enthusiasm in the health care community, use of simulation in health care education is limited to specific areas and is not a budgeted item in many institutions. Absence of a sustainable business model, as well as sufficient financial support in terms of budget, infrastructure, manpower, research, and scholarly activities, slows down the movement of simulation. Specific recommendations are made based on current findings to support simulation in the next developmental stages.

A multifunctional online research portal for facilitation of simulation-based research: a report from the EXPRESS pediatric simulation research collaborative.

Introduction: Simulation-based research requires the coordinated effort of research teams to design projects, recruit subjects, and carry out performance assessments of individuals or teams. These efforts can often be labor intensive, time consuming, and logistically challenging, especially in the context of multicenter simulation-based research trials. Methods: We have developed a multifunctional, internet-based research portal for facilitation of simulation-based research. This free portal, accessible from www.cesei.org, is capable of managing the research process by helping researchers to design their project, setup data collection using customized assessment tools, upload videos for performance assessment, and finally, download data-filled spreadsheets for statistical analysis. Results: The research portal has been used successfully to manage the first major project of the EXPRESS research collaborative, a multicenter research study involving 15 recruitment sites and more than 400 subjects. Conclusions: The use of the research portal has enabled us to simplify and streamline the management of our multicenter research studies. We envision that this portal will permit novice and expert researchers alike to carry out their simulation-based research projects in a coordinated and time-efficient fashion, thus ultimately helping to enhance their overall research productivity.

Surgical Skills Lab: A Hub for Competency Training

ABSTRACT Simulation is considered to be a paradigm shift in surgical education and skills acquisition. Today simulation is accepted to be a new concept not only for Surgery but also for the entire health education. This paper aims to improve the awareness of simulation technology and is to assist those individuals and institutions who are in the process of building a simulation centre or envisioning the formation of a simulation program in their future endeavors. The author shares his experience with the medical community and provides information to access other resources in support of simulation programs.

Centers of excellence: a new dimension in surgical education.

Surgical education has always been challenging and is being made more difficult with the changes in the surgical environment. In the past decade, the number of patients available for educational purposes has decreased because of the development of technology that has significantly reduced their time of stay in the hospital and has also moved many surgical procedures to ambulatory services. Technologic advances also create the demand for more specialized training. The increased number of undergraduate, postgraduate students, and clinical fellows has also affected the educational mandate of the academic hospitals. Alternative ways to teach medicine, and especially surgery, are becoming inevitable. One such method is to teach students outside the operating room in a simulated environment. This article reports on the developments of surgical education centers and provides guidance for those who might wish to develop such educational facilities. For further information, visit www.cesei.org.

Biphasic release of immunoreactive endothelins following acute pulmonary thromboembolism in pigs.

The purpose of this investigation was to study the role of endothelins (ETs) in the pathogenesis of acute pulmonary thromboembolism (PTE). Eighteen piglets (20 +/- 3 kg) were anesthetized and ventilated with 100% oxygen, five of them then served as controls. Acute thromboembolic injury in the lung was induced by injecting 15-25 ml of preformed clots into the left lower lobar pulmonary artery during thoracotomy. Pulmonary arterial pressure (Ppa) increased by at least 2.5-fold from baseline. During the subsequent 8 h, seven blood samples were collected from the left atrium and assayed for immunoreactive ETs. The results showed that following PTE: (1) Ppa remained elevated but cardiac output remained constant throughout the experiments; (2) plasma level of immunoreactive ETs increased in the embolized group compared to controls and the profile of immunoreactive ET release suggested a biphasic response. We conclude that the release of these vasocontractile and bronchoconstrictive mediators after PTE may contribute to ventilation perfusion mismatching and account for the pulmonary hypertension and deterioration of gas exchange that are often seen clinically.

Objective Assessment of Laparoscopic Skills Dual-Task Approach

Background. Assessment of surgical performance is often accomplished with traditional methods that often provide only subjective data. Trainees who perform well on a simulator in a controlled environment may not perform well in a real operating room environment with distractions. This project uses the ideas of dual-task methodology and applies them to the assessment of performance of laparoscopic surgical skills. The level of performance on distracting secondary tasks while trying to perform a primary task becomes an indirect but objective measure of the surgical skill of the trainee. Methods. Nine surgery residents and 6 experienced laparoscopic surgeons performed 3 primary tasks on a laparoscopic virtual reality simulator (camera position, grasping, and cholecystectomy) while being distracted by 3 secondary tasks (counting beeps, selective responses, and mental arithmetic). Completion time and error rates were recorded for each combination of tasks. Results. When performed separately, time to completion and error rates for primary and secondary tasks were similar for learners and experts. When performing the tasks simultaneously, learners had more errors than experts. Error rates increased for learners when distracting tasks became more difficult or required more attention. Expert surgeons maintained consistent error rates despite the increasing difficulty of task combinations. Conclusions. The use of dual-task methodology may help trainers to identify which surgical trainees require more preparation before entering the real operating room environment. Expert surgeons are capable of maintaining performance levels on a primary task in the face of distractions that may occur in the operating room.

British Columbia interprofessional model for simulation-based education in health care: a network of simulation sites.

The rapid uptake of simulation-based education has led to the development of simulation programs and centers all around the world. Unfortunately, many of these centers are functioning as localized silos and not taking advantage of the potential for collaboration with other regional centers to promote interprofessional education. In the province of British Columbia (BC), Canada, 38 institutions, including health care authorities, universities, colleges, and other health-related organizations, have participated in assessing the use of simulation in BC and in developing a provincial model that enables collaboration and interprofessional learning at the provincial level. This article describes methods and results of a needs assessment and discusses an interprofessional simulation in health care educational model that provides access for all health care professionals in BC regardless of their geographic location and/or institutional affiliation. We anticipate that this information will be useful to and supportive of others in developing simulation collaborations in their respective regions.