Surgical experience and identification of errors in laparoscopic cholecystectomy.

BACKGROUND: Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS: Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS: Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION: This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents.

OBJECTIVE: This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times. DESIGN: Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10. SETTING: Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care. PARTICIPANTS: Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents. RESULTS: 159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases. CONCLUSIONS: Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

The impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy: meta-analysis of randomized clinical trials.

BACKGROUND: Simulation training can improve the learning curve of surgical trainees. This research aimed to systematically review randomized clinical trials (RCT) evaluating the performance of junior surgical trainees following virtual reality training (VRT) and other training methods in laparoscopic cholecystectomy. METHODS: MEDLINE (PubMed), Embase (Ovid SP), Web of Science, Scopus and LILACS were searched for trials randomizing participants to VRT or no additional training (NAT) or simulation training (ST). Outcomes of interest were the reported performance using global rating scores (GRS), the Objective Structured Assessment of Technical Skill (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS), error counts and time to completion of task during laparoscopic cholecystectomy on either porcine models or humans. Study quality was assessed using the Cochrane Risk of Bias Tool. PROSPERO ID: CRD42020208499. RESULTS: A total of 351 titles/abstracts were screened and 96 full texts were reviewed. Eighteen RCT were included and 15 manuscripts had data available for meta-analysis. Thirteen studies compared VRT and NAT, and 4 studies compared VRT and ST. One study compared VRT with NAT and ST and reported GRS only. Meta-analysis showed OSATS score (mean difference (MD) 6.22, 95%CI 3.81 to 8.36, P < 0.001) and time to completion of task (MD -8.35 min, 95%CI 13.10 to 3.60, P = <0.001) significantly improved after VRT compared with NAT. No significant difference was found in GOALS score. No significant differences were found between VRT and ST groups. Intraoperative errors were reported as reduced in VRT groups compared with NAT but were not suitable for meta-analysis. CONCLUSION: Meta-analysis suggests that performance measured by OSATS and time to completion of task is improved with VRT compared with NAT for junior trainee in laparoscopic cholecystectomy. However, conclusions are limited by methodological heterogeneity and more research is needed to quantify the potential benefit to surgical training.

The educational value of the multi-disciplinary meeting (MDM) in surgical oncology: A systematic review and thematic content analysis.

Multidisciplinary meetings are an important part of cancer care and surgical planning. However, there is also an important educational role of MDMs in training the next generation of surgical oncologists. This systematic review (SR) aimed to examine the current educational role of the surgical oncology MDM and identify areas for improving educational value. Medline, OVID, EMBASE, CINHIL and Web of Science were searched using a predefined search strategy in keeping with the PRISMA statement. Data was analysed and synthesized in narrative format and thematic content analysis was performed. Three main groups of studies were identified, those with: 1. A simulated non-clinical MDM (3/13), 2. clinical MDMs with a defined educational intervention (1/13) and 3. observational studies that described the educational benefit of the clinical MDM with no intervention (9/13). Satisfaction rates were high and learning outcomes improved where an intervention to improve the educational content of the MDM had been implemented(simulated or non-simulated). Respondents considered the MDM a valuable tool for learning non-technical skills and training surgical oncologists and medical students. Using defined interventions e.g. debriefing post MDM, or simulation can improve the educational benefit for learners. Qualitative analysis identified clinical knowledge, decision making and the acquisition of non-technical skills as the key themes within included studies.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm.

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.

Real-world use of workplace based assessments in surgical training: A UK nationwide cross-sectional exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training.

BACKGROUND: Despite widespread uptake, the utility of Workplace Based Assessments (WBAs) is disputed and evidence underpinning their use is largely based upon their completion in ideal conditions, rather than the real-world setting. AIM: To ascertain the real-world usage of WBAs, as perceived by UK surgical trainees. MATERIALS AND METHODS: An anonymous online questionnaire conducted nationally via the Association of Surgeons in Training (ASiT). Evaluation of 906 completed trainee responses, across all surgical specialties and training levels, employed mixed methods to interpret quantitative and qualitative data. RESULTS: The sample permitted a 3.0% confidence level with acceptable internal consistency (Cronbach's alpha 0.755). Formative use was supported by 72.5% and summative use was rejected by almost as many (66.3%). WBA use was perceived to deviate markedly from that recommended by the Joint Committee on Surgical Training (JCST). Significant misuse was identified and elements perceived as inaccurate appear commonplace across the breadth of surgical specialties. Inaccurate completion was acknowledged by 89.6% of respondents and some trainers appear complicit, 147 individuals (16.2%) having reported this to trainers, 40.9% aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers. Furthermore, a majority of trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Reasons for misuse appeared largely centred upon time restraints, lack of engagement and a will to achieve the required targets for career progression. 1.5 CONCLUSIONS: This study demonstrates that UK surgical trainees perceive that most trainees deviate from guidance in their use of WBAs. This is worrying in both the apparent frequency and nature of misuse and somewhat undermines existing evidence for their role in surgical training. Trainees perceive that required numbers of WBAs are too high, that training programmes fail to encourage their use as formative assessments, and that there is a lack of engagement by many trainees and trainers. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.

Bullying and undermining behaviours in surgery: A qualitative study of surgical trainee experiences in the United Kingdom (UK) & Republic of Ireland (ROI).

BACKGROUND: Bullying and undermining (B/U) behaviours are documented in the international surgical workplace. This study is the largest assessment of prevalence of B/U behaviours within UK & ROI surgical training to date. MATERIALS AND METHODS: UK & ROI surgical trainees were electronically surveyed in July 2017. The survey was open for one month and sent to all registered trainees at Core and Specialty level by the Joint Committee on Surgical Training (JCST) along with email and social media dissemination by the Association of Surgeons in Training (ASiT) and the British Orthopaedic Trainees Association (BOTA). A consensus session on the topic was conducted at the ASiT Conference in Edinburgh in March 2018. Standards for reporting of Qualitative Research were followed. RESULTS: 1412 responses were received (26.6% response rate). All training regions, grades and specialties were represented. 60% of trainees (n = 837) reported witnessing or experiencing B/U behaviours in the surgical workplace. The most common reports related to sexism; 42% (n = 568) reported witnessing or experiencing sexist language/attitudes in the workplace. This was reported more by female respondents (66% compared to 27% male). 21% (n = 291) and 13% (n = 180) reported witnessing or personally experiencing racist and homophobic language or attitudes respectively. Consultants were identified as the most frequent perpetrators. The surgical wards or theatres were the most frequently reported areas that trainees either witnessed or experienced B/U behaviours. Of those trainees who had reported a personal experience of B/U behaviours (n = 344), 20% described their experiences of reporting as negative or very negative. 48.1% of respondents felt that surgery as a whole had a moderate, high or very high degree of a concern about B/U behaviours. CONCLUSION: B/U behaviours are prevalent in the surgical domain. Urgent action is required to eradicate this unacceptable behaviour. A cross-specialty, intercollegiate response is required to tackle this issue and improve the working culture in surgery for all.

Consensus recommendations on balancing educational opportunities and service provision in surgical training: Association of Surgeons in Training Delphi qualitative study.

BACKGROUND: Ensuring the highest quality of surgical training remains a challenge as demands on health service provision rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity provided by surgical trainees, and recommend solutions. METHODS: Participants were drawn from the Association of Surgeons in Training (ASiT) national council. Nominal Group Technique (NGT) was employed by members of the ASiT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two-round Delphi process was conducted via electronic survey to ASiT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement. RESULTS: 47 statements were generated through NGT which were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as being activities which progressed a trainee's skill set, could be tailored to a trainee's own ability, and involved acting as a trainer to more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers. CONCLUSION: This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.

Adjuvant treatment of chronic osteomyelitis of the tibia following exogenous trauma using OSTEOSET(®)-T: a review of 21 patients in a regional trauma centre.

Surgical debridement and prolonged systemic antibiotic therapy are an established management strategy for infection after tibial fractures. Local antibiotic delivery via cement beads has shown improved outcome but requires further surgery for extraction of beads. OSTEOSET(®)-T is a resorbable bone void filler composed of calcium sulphate and 4 % tobramycin that is packed easily into bone defects. This is a review of the outcomes of 21 patients treated with OSTEOSET(®)-T for osteomyelitis of the tibia. This is a retrospective case note and clinical review. In all cases, the strategy was debridement, with removal of any implants, with excision back to bleeding bone. OSTEOSET(®)-T pellets were packed into any contained defects or the intra-medullary canal with further bony stabilisation (n = 9) and soft tissue reconstruction (n = 7) undertaken as required. Intravenous vancomycin and meropenem were administered after sampling with substitution to targeted antibiotic therapy for between 6 weeks and 6 months. The average follow-up was 15 months. Union rate after tibial reconstruction was 100 %. Wound complications were encountered in 52 %: a wound discharge in the early post-operative period was noted in seven patients (33 %) independent of site of pellet placement. In the 14 cases without a wound leak, five developed wound complications (p = 0.06, Fisher's exact test) either from delayed wound-healing or pin-site infections. One patient developed a transient acute kidney injury and one refractory osteomyelitis. OSTEOSET(®)-T is an effective adjunct in the treatment of chronic tibial osteomyelitis following trauma based on the low incidence of relapse of infection within the period of follow-up in this study, but significant wound complications and one transient nephrotoxic event were also recorded.