Assessing the safety and learning curve of a neurosurgical trainee in performing a microvascular decompression (MVD).

Purpose: MVD is complex procedure when done safely can be effective in managing Trigeminal Neuralgia. Here we assess the safety and learning curve of a surgical trainee in performing a MVD. Methods: A retrospective analysis of patients who have undergone MVD by the trainee (07/2014-07/2017) and by the senior neurosurgeon (03/2011-04/2015). Data such as surgery time, length of stay, outcomes and complications were collected. Results: Out of the 18 cases of MVD were performed by the trainee, 10 were supervisor trainer unscrubbed (STU) or performed (P) and 8 were supervisor trainer scrubbed (STS). Mean surgical time was 2:30 hrs and mean length of stay was 6.33 days. The mean outcome score was 2.33/3 with 89% cases a positive outcome. The complication rate was 16.7%, of which one had meningitis, one had CSF leak and one developed a pseudomeningocele. The trainee's surgery time, outcomes and complication rates were comparable to trainer and the literature. There was a statistically significant correlation between number MVD performed and operative time (R = -0.50, p < .05), intervals between MVDs and complication rates (R = 0.64, p < .05), and interval between MVDs and outcome scores (R = -0.66, p < .05). We estimate the time between cases should be below 40 days. Conclusions: Training a trainee is safe and does not add much burden to the hospital. A trainee will benefit the most if they have the same supervisor at least for the first eight cases and that each case should be done within 40 days of each other.

Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model.

BACKGROUND: Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. OBJECTIVE: To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. METHODS: For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. RESULTS: A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. CONCLUSION: This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.