A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass.

BACKGROUND: The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based. METHODS: Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling). CONCLUSION: This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

Intraluminal indocyanine green for intraoperative staple line leak testing in bariatric surgery.

BACKGROUND: Bariatric surgical procedures have recognized benefits for morbidly obese patients. Unfortunately, staple line leaks remain a profound complication after these procedures. Currently available intraoperative surveillance modalities have multiple drawbacks, such as requiring an available upper endoscope and experienced endoscopist. Additionally, increased procedure time and resources are needed to perform intraoperative endoscopy and maintain equipment. METHODS: This is a retrospective cohort study of all bariatric patients undergoing Roux-en-Y gastric bypass or sleeve gastrectomy procedures performed by one attending surgeon at a tertiary care facility designated as a bariatric surgical center of excellence. Patients were grouped based on procedure date being before (September 2016 to mid-October 2018) or after (mid-October 2018 to March 2019) implementation of a novel intraluminal indocyanine green leak testing protocol. Diluted indocyanine green was injected via orogastric bougie intraluminally at the location of the gastric staple line and observed with near-infrared imaging from the intraperitoneal perspective for evidence of immunofluorescence extravasation. Data from the electronic medical record and bariatric surgical outcomes database were gathered to analyze the sensitivity and specificity of this new intraoperative diagnostic modality. RESULTS: Total of 196 patients underwent bariatric surgery with intraoperative leak testing using the gastroscopy method; of these, there were 3 false negatives and 193 true negatives. Total of 59 patients underwent bariatric surgery with intraoperative leak testing using the intraluminal ICG method; of these, there was 1 true positive, 1 false positive, 0 false negatives, and 57 true negatives. Indocyanine green leak testing had a sensitivity of 100.00% and specificity of 98.28%. CONCLUSIONS: Intraluminal indocyanine green is an alternative for intraoperative detection of staple line integrity during bariatric surgical procedures with comparable specificity to intraoperative gastroscopy.