Acute surgical emergencies in patients at or near the end of life.

Patients with advanced or incurable preexisting illnesses often develop acute surgical emergencies. The decision to proceed with aggressive surgical intervention or provide comfort measures and symptomatic relief is often difficult. This article provides an organized overview of the multiple considerations required to produce optimal patient outcome.

Determining standards for laparoscopic proficiency using virtual reality.

Laparoscopic training using virtual reality has proven effective, but rates of skill acquisition vary widely. We hypothesize that training to predetermined expert levels may more efficiently establish proficiency. Our purpose was to determine expert levels for performance-based training. Four surgeons established as laparoscopic experts performed 11 repetitions of 12 tasks. One surgeon (EXP-1) had extensive Minimally Invasive Surgical Trainer-Virtual Reality (MIST VR) exposure and formal laparoscopic fellowship training. Trimmed mean scores for each were determined as expert levels. A composite score (EXP-C) was defined as the average of all four expert levels. Thirty-seven surgery residents without prior MIST VR exposure and two research residents with extensive MIST VR exposure completed three repetitions of each task to determine baseline performance. Scores for EXP-1 and EXP-C were plotted against the best score of each participant. On average, the EXP-C level was reached or exceeded by 7 of the 37 (19%) residents. In contrast, the EXP-1 level was reached or exceeded by 1 of 37 (3%) residents and both research residents on all tasks. These data suggest the EXP-C level may be too lenient, whereas the EXP-1 level is more challenging and should result in adequate skill acquisition. Such standards should be further developed and integrated into surgical education.

Developing and testing competency levels for laparoscopic skills training.

HYPOTHESIS: Expert levels can be developed for use as training end points for a basic video-trainer skills curriculum, and the levels developed will be suitable for training. DESIGN: Fifty subjects with minimal prior simulator exposure were enrolled using an institutional review board-approved protocol. As a measure of baseline performance, medical students (n = 11) and surgery residents (n = 39) completed 3 trials on each of 5 validated video-trainer tasks. Four board-certified surgeons established as laparoscopic experts (with more than 250 basic and more than 50 advanced cases) performed 11 trials on each of the 5 tasks. The mean score was determined and outliers (>2 SDs) were trimmed; the trimmed mean was used as the competency level. Baseline performance of each subject was compared with the competency level for each task. SETTING: All research was performed in a laparoscopic skills training and simulation laboratory. PARTICIPANTS: Medical students, surgical residents, and board-certified surgeons. MAIN OUTCOME MEASURES: Expert scores based on completion time and the number of subjects achieving these scores at baseline testing. RESULTS: For all tasks combined, the competency level was reached by 6% of subjects by the third trial; 73% of these subjects were chief residents, and none were medical students. CONCLUSIONS: These data suggest that the competency level is suitably challenging for novices but is achievable for subjects with more experience. Implementation of this performance criterion may allow trainees to reliably achieve maximal benefit while minimizing unnecessary training.

Acute endovascular management of a subclavian artery injury.

Traumatic injuries to the subclavian vessels are relatively uncommon and surgical repair may be technically challenging. With the increasing availability of endovascular techniques for nontraumatic arterial disease, an increase in the use of stenting for traumatic vascular injuries can be expected. This report describes the fifth successful endovascular repair with stenting of a pseudoaneurysm of the subclavian artery as a result of blunt trauma, and the first American report of such repair used in the acute or immediate management of blunt subclavian artery injury.