Surgical team composition differs between laparoscopic and open procedures.

BACKGROUND: Performing laparoscopic procedures requires different skill sets and team dynamics compared with open procedures. We evaluated team composition and procedure time between these two surgical approaches using data collected from hospitals in the United State and Canada. METHODS: A total of 1,260 general surgical cases were reviewed retrospectively, recording the number of operation personnel, procedure complexity, and the procedure time. RESULTS: Laparoscopic procedures (n = 930), on average, had a higher procedure difficulty coding which led to a longer procedure time and involved more people in the surgical team than open procedures (n = 330). When we selected cases with matched procedure difficulty coding, laparoscopic procedures (n = 450) still required longer procedure times and involved more operative personnel than open procedures (n = 92). DISCUSSION: Increased laparoscopic team size and procedure time must be influenced by factors other than case difficulty. The factors may derive from inherent complexity of the surgical setting and team dynamics unique to laparoscopic procedures.

Maintaining forward view of the surgical site for best endoscopic practice.

Endoscopic surgery performed through patients' natural orifices (NOTES procedures) often require some degree of retroflexion of the operating system. This can cause a misalignment between the displayed image and the actual work plane, leading to performance difficulties. This study investigated the impact of retroflexion on task performance in a simulated environment. Surgeons were required to perform an aiming and pointing task under two experimental conditions: forward-view vs. retroflexed-view. Results showed that both expert and novice surgeons required significantly longer time for completing the task when the scope was retroflexed, compared to when the scope faced forwards. Results address the importance of careful selection of the surgical approach to avoid image retroflexion. Further analysis revealed that the novices were more vulnerable than experts to image distortion with the retroflexed view. This addresses the necessity for surgeons to go through extensive endoscopic training to overcome the visual-motor challenges before they can perform NOTES procedures safely and effectively.

Feasibility of using intraoperatively-acquired quantitative kinematic measures to monitor development of laparoscopic skill.

The objective of this paper is to present the initial results of a study aimed at showing the feasibility of using kinematic measures to distinguish skill levels in manipulating surgical tools. Through a simulated surgical task (dissection of a mandarin orange), we acquired motor performance data from three sets of subjects representing different stages of surgical training. We computed the average lateral, axial and vertical tooltip velocities for each of the two main subtasks ('Peel Skin' and 'Detach Segment'). For each subject, we defined a 6-element vector to describe the kinematic measures extracted from the two tasks and used Principal Components Analysis (PCA) to extract the two dominant contributors to overall variability to simplify the presentation of the data to the trainer. We found that the first two principal components accounted for approximately 90% of the variance across all subjects and tasks. Moreover, the PCA plot showed good intrasubject repeatability, consistency within subjects with similar levels of training, and good separation between the subject groups. The results of this pilot study will allow us to design a future intraoperative study.

Assessing cognitive & motor performance in minimally invasive surgery (MIS) for training & tool design.

The objective of this paper is to present the development of a new modelling diagram (MCMD) to represent MIS procedures in terms of both motor and cognitive actions. Through observation and analysis of several laparoscopic cholecystectomy procedures and based on task analysis techniques, we created a diagram language composed of six primary symbols: processes, decisions, interrupt service routines (ISRs), options points and AND and OR gates. We then tested and refined them during 10 new cases until no further changes seemed necessary, we have since applied this approach to 6 laparoscopic colorectal surgeries and have found that no further symbols were necessary though the procedural representation was naturally different. This modelling diagram allowed us to represent both cognitive and motor performance aspects of surgical procedures in a unified framework and will in future allow us to assess motor performance on particular surgical tasks at particular points in the procedure (i.e., the surgical context).