Liane S. Feldman

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.

Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial

BACKGROUND The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the operating room (OR). METHODS Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores <or=15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. RESULTS Sixteen residents completed the study. There were no differences in baseline simulator (49.1 +/- 17 vs 39.5 +/- 16, P = .27) or OR scores (11.3 +/- 2.0 vs 12.0 +/- 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 +/- 4 vs 60.5 +/- 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 +/- 2.2 (P = .04), whereas the trained group improved by 6.1 to 17.4 +/- 1.9 (P = .0005 vs control; P < .0001 vs baseline). CONCLUSIONS This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.

Background:In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. Methods:A systematic review (1980–2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality. Results:A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented. Conclusions:Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

Background:The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods:A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results:Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. −21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion:Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

Randomized clinical trial of prehabilitation in colorectal surgery

‘Prehabilitation’ is an intervention to enhance functional capacity in anticipation of a forthcoming physiological stressor. In patients scheduled for colorectal surgery, the extent to which a structured prehabilitation regimen of stationary cycling and strengthening optimized recovery of functional walking capacity after surgery was compared with a simpler regimen of walking and breathing exercises.

The MISTELS program to measure technical skill in laparoscopic surgery

BackgroundThe McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) is a series of five tasks with an objective scoring system. The purpose of this study was to estimate the interrater and test–retest reliability of the MISTELS metrics and to assess their internal consistency.MethodsTo determine interrater reliability, two trained observers scored 10 subjects, either live or on tape. Test–retest reliability was assessed by having 12 subjects perform two tests, the second immediately following the first. Interrater and test–retest reliability were assessed using intraclass correlation coefficients. Internal consistency between tasks was estimated using Cronbach’s alpha.ResultsThe interrater and test–retest reliabilities for the total scores were both excellent at 0.998 [95% confidence interval (CI), 0.985–1.00] and 0.892 (95% CI, 0.665–0.968), respectively. Cronbach’s alpha for the first assessment of the test–retest was 0.86.ConclusionsThe MISTELS metrics have excellent reliability, which exceeds the threshold level of 0.8 required for high-stakes evaluations. These findings support the use of MISTELS for evaluation in many different settings, including residency training programs.

FLS simulator performance predicts intraoperative laparoscopic skill

IntroductionSimulators are being used more and more for teaching and testing laparoscopic skills. However, it has yet to be firmly established that simulator performance reflects operative laparoscopic skill. The study reported here was designed to test the hypothesis that laparoscopic simulator performance predicts intraoperative laparoscopic skill.MethodsA review of our prospectively maintained database identified 40 subjects who underwent Fundamentals of Lapraoscopic Surgery (FLS) skills testing and objective intraoperative assessments within the same 6-month period. Subjects consisted of 22 novice (postgraduate year [PGY] 1–2), 10 intermediate (PGY 3–4), and 8 experienced (PGY 5, fellows, and attendings) laparoscopic surgeons. Laparoscopic performance was objectively assessed in the operating room using the previously validated Global Operative Assessment of Laparoscopic Skill (GOALS). Analysis of variance (ANOVA) was used to compare mean FLS scores and mean GOALS scores across experience levels. The relationship between individual FLS scores and GOALS scores was assessed with linear regression analysis. A multivariate analysis evaluated FLS score and surgeon experience as predictors of intraoperative GOALS score. A receiver-operator curve (ROC) was constructed in order to define an FLS cutoff score that predicts intraoperative performance at or above the level of experienced surgeons. Significance was defined as p < 0.05.ResultsMean FLS scores and mean GOALS scores increased with increasing experience. Individual FLS scores correlated significantly with intraoperative GOALS scores (0.77, p < 0.001). Multivariate analysis confirmed that FLS score is an independent predictor of intraoperative GOALS scores. The ROC identified an FLS cutoff score of 70 with optimal sensitivity (91%) and specificity (86%) for predicting a GOALS score at or above the level of experienced surgeons.ConclusionsIn this study sample, FLS simulator scores were independently predictive of intraoperative laparoscopic performance as measured by GOALS. More precisely, an FLS cutoff score of 70 optimized sensitivity and specificity for expert intraoperative performance. A larger prospective study is justified to validate these findings.

Effect of pneumoperitoneum on renal perfusion and function: A systematic review

BackgroundThe precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function.MethodsA literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings—renal blood flow, pneumoperitoneum, renal function, and laparoscopy—were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles.ResultsThe literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum.ConclusionThere appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.

Measuring postoperative complications in general surgery patients using an outcomes-based strategy: Comparison with complications presented at morbidity and mortality rounds

BACKGROUND This study was undertaken to compare the incidence of adverse postoperative outcomes recorded in a prospective general surgery database with that identified through weekly morbidity and mortality (M&M) rounds and to measure the impact of feedback of information to the providers of care. METHODS Data were collected on patients admitted to one general surgery service between October 1, 1995, and May 15, 1996, and recorded in a computer database. Postoperative complications were graded in severity from I (minor) to IV (mortality). RESULTS Of 479 admissions entered into the database during the study period, 325 (311 patients) led to operations and were further analyzed. Admissions resulting in complications were associated with longer hospital stays, regardless of complication grade, compared to uncomplicated admissions (p < 0.01). A total of 29 of 106 patients with postoperative complications were presented at M&Ms (27.4%). Whereas 15.4% of database patients with grade I complications were presented at M&Ms, this proportion increased to 22.2% for grade IIa, 34.8% for grade IIb, 33.3% for grade III, and 87.5% for grade IV. (p < 0.05 for grade I, IIa, and IIb compared to grade IV). A total of 58 of 142 patients in the first part of the study period developed complications (40.8%), compared to 53 of 183 patients in the second part of the study (29%, p = 0.034). CONCLUSIONS Although most severe complications are recorded at M&M rounds, a large proportion of complications remain unreported. Monitoring of outcomes may contribute to improvements in quality of care.

Intraoperative Esmolol Infusion in the Absence of Opioids Spares Postoperative Fentanyl in Patients Undergoing Ambulatory Laparoscopic Cholecystectomy

BACKGROUND:The use of opioids during ambulatory surgery can delay hospital discharge or cause unexpected hospital admission. Preliminary studies using an intraoperative continuous infusion of esmolol in place of an opioid have inconsistently reported a postoperative opioid-sparing effect. In this study, we compared esmolol versus either intermittent fentanyl or continuous remifentanil on postoperative opioid-sparing, side effects, and time of discharge. METHODS:Ninety patients (consisting of three groups) were enrolled in this prospective, randomized, and observer-blinded study. The control group (n = 30) received intermittent doses of fentanyl, the esmolol group (n = 30) received a continuous infusion of esmolol (5–15 &mgr;g · kg−1 · min−1) and no supplemental opioids during surgery, and the remifentanil group (n = 30) received a continuous infusion of remifentanil (0.1–0.5 &mgr;g · kg−1 · min−1). General anesthesia was standardized, and adjuvant medications included acetaminophen, ketorolac, local anesthetics in the skin incisions, dexamethasone, and droperidol. Postoperative analgesia included fentanyl. RESULTS:The amount of fentanyl in the postanesthesia care unit was significantly less in the esmolol group, 91.5 ± 42.7 &mgr;g, compared with the other two groups, remifentanil, 237.8 ± 54.7 &mgr;g, control, 168.1 ± 96.8 &mgr;g (P < 0.0001). The incidence of nausea was more frequent in the control (66.7%) and remifentanil (67.9%) groups compared with the esmolol group (30%) (P < 0.01). The esmolol group reached the White-Song score of 12 of 14 faster than the remifentanil group (P < 0.01), and left the hospital 45–60 min earlier (P < 0.004). CONCLUSIONS:Intraoperative IV infusion of esmolol contributes to a significant decrease in postoperative administration of fentanyl and ondansetron and facilitates earlier discharge.