The Complexity of the Retropubic Midurethral Sling: A Cognitive Task Analysis.

OBJECTIVE: The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon's internal thought processes during the surgery. METHODS: Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery. RESULTS: Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps). CONCLUSIONS: The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

Constructivist Grounded Theory to Establish the Relationship Between Technical Error and Adverse Patient Outcome: Modeling Technical Error and Adverse Outcomes.

BACKGROUND: Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes. MATERIALS AND METHODS: We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons. RESULTS: Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss. DISCUSSION: Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Risk Factors for Returning to the Operating Room for a Second Surgery After Midurethral Sling for Stress Urinary Incontinence.

OBJECTIVES: The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS). METHODS: We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis. RESULTS: Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders. CONCLUSIONS: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.

Dopamine signaling in the medial prefrontal cortex and amygdala is required for the acquisition of fructose-conditioned flavor preferences in rats.

Systemic administration of dopamine (DA) D1 (SCH23390: SCH) and D2 (raclopride: RAC) antagonists blocked both acquisition and expression of fructose-conditioned flavor preferences (CFP). It is unclear what brain circuits are involved in mediating these effects. The present study investigated DA signaling within the nucleus accumbens shell (NAcS), amygdala (AMY) and medial prefrontal cortex (mPFC) in the acquisition and expression of fructose-CFP. In Experiment 1, separate groups of rats were injected daily in the NAcS or AMY with saline, SCH (24 nmol) or RAC (24 nmol) prior to training sessions with a flavor (CS+) mixed with 8% fructose and 0.2% saccharin (CS+/F) and a different flavor (CS-) mixed with only 0.2% saccharin. In the two-bottle choice tests with 0.2% saccharin, only rats injected with RAC in the AMY failed to acquire a CS+ preference (45-54%). In Experiment 2, new rats were identically trained, but saline, SCH and RAC were injected in the mPFC. In subsequent two-bottle choice tests, SCH- and RAC-treated rats failed to exhibit a CS+ preference (50-56%). In Experiment 3, new rats were trained with CS+/F and CS- without injections. Subsequent two-bottle choice tests were then conducted following bilateral injections of SCH or RAC in the mPFC at total doses of 0, 12, 24 and 48 nmol. Expression of the CS+ preference failed to be affected by either antagonist, indicating that the mPFC is not involved in the maintenance of this preference. These data indicate that the acquisition of fructose-CFP is dependent on DA signaling in the mPFC and AMY.