Effects of Individualized Nursing Based on Zero-Defect Theory on Perioperative Patients Undergoing Laparoscopic Cholecystectomy.

Objective: This study is aimed at analyzing the effects of individualized nursing based on the zero-defect theory on perioperative patients undergoing laparoscopic cholecystectomy. Methods: 174 patients who underwent laparoscopic cholecystectomy from 1st November 2019 to 30th November 2020 were enrolled as the research subjects and randomly divided into control and observation groups. The patients in the control group received conventional perioperative nursing care, and the patients in the observation group were treated with individualized nursing based on the zero-defect theory. Results: The heart rate, diastolic blood pressure, and systolic blood pressure level of patients in two groups after nursing decreased significantly, and the reduction in the observation group was more significant than that in the control group. The depression and anxiety scores of the two groups after nursing were decreased, and the decrease in the observation group was significantly greater than that in the control group. The time to first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group. The incidence of postoperative complications in the observation group was substantially lower than that in the control group. The satisfaction degree of nursing care in the observation group was significantly higher than that in the control group. Conclusion: Individualized nursing care based on zero-defect theory can effectively reduce the perioperative psychological stress response of patients with laparoscopic cholecystectomy. It helps to improve the negative emotions of depression and anxiety, promotes the recovery of disease, reduces postoperative complications, and improves nursing satisfaction, which is worthy of clinical promotion.

Can general surgeons perform laparoscopic surgery independently within 10 years of training? A nationwide survey on laparoscopic surgery training in Japan.

PURPOSE: There is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan. METHODS: A questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures. RESULTS: The total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy. CONCLUSIONS: The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan.

Colangiografía intraoperatoria: curva de aprendizaje en una Residencia de Cirugía General / Intraoperative cholangiography: Learning curve in a General Surgery residency

RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.

ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Preoperative communication with anesthetists via anesthesia service platform (ASP) helps alleviate patients' preoperative anxiety.

Female gender has been identified as one of the risk factors closely linked to perioperative anxiety and a lower level of satisfaction. A successful preoperative anesthesia education may improve such negative outcomes. The aim of this study was to investigate whether preoperative anesthesia education via an Anesthesia Service Platform (ASP) could reduce the anxiety levels in female patients scheduled for laparoscopic cholecystectomy under general anesthesia, and accelerate rehabilitation. A total of 222 patients scheduled for elective laparoscopic cholecystectomy were randomly assigned to the control group and the ASP group. Patients' baseline and post-intervention psychological status was measured by the State-Trait Anxiety Inventory and General Well-Being Schedule. Pain management and recovery were assessed by VAS every 12 h for 48 h after surgery; length of stay (LOS) and postoperative analgesic consumption were also assessed. Patients in the control group experienced higher anxiety levels before surgery and had longer LOS than those in the ASP group. Patients in the ASP group had a higher general well-being score; however, they suffered more pain and consumed more analgesics after surgery. ASP is effective for preventing anxiety in female patients before laparoscopic cholecystectomy, improving patients' general well-being levels, and shortening their LOS, but negatively influences patients' postoperative pain levels.

Efficacy of Hand and Foot Massage in Anxiety and Pain Management Following Laparoscopic Cholecystectomy: A Controlled Randomized Study.

This study was planned and performed to evaluate the effect of foot and hand massage on pain and anxiety management, which is one of the nonpharmacological pain relief methods in patients who undergo laparoscopic cholecystectomy. The present study was designed and conducted in the randomized controlled manner to determine the impacts of foot and hand massage on postoperative pain and anxiety scores of patients who receive laparoscopic cholecystectomy. The universe of the study consisted of the patients who received laparoscopic cholecystectomy between April 2018 and January 2019. The study was completed with 196 patients as 63 patients in the foot massage group, 65 patients in the hand massage group, and 68 patients in the control group. To collect the data, the "Descriptive Characteristics Form," "Visual Analog Scale," and "State-Trait Anxiety Inventory" were used. The pain intensity of patients in the foot massage group and hand massage group were less than in the control group at 90 and 150 minutes after intervention (P<0.05). A significant reduction was determined in the need for analgesics for the patients in the foot massage group and hand massage group compared with the control group (P<0.05). A significant positive relationship was found between pain intensity and state anxiety levels in patients of the foot massage group and hand massage group. Foot and hand massage are influential in decreasing pain and anxiety levels after surgeries for patients who undergo laparoscopic cholecystectomy.

Adrenocorticotropic Hormone (ACTH) and Cortisol Monitoring as Stress Markers During Laparoscopic Cholecystectomy: Standard and Low Intraabdominal Pressure and Open Cholecystectomy.

INTRODUCTION: In this study we wanted to examine the hormonal responses due to stress exposure during laparoscopic cholecystectomy with standard (12-15 mm / Hg) (LCSP) and low (6-8 mm / Hg) (LCLP) intraabdominal pressure and open cholecystectomy (OC), with particular emphasis on stress hormone responses. AIM: Determination of adrenocorticotropic hormone (ACTH) and cortisol stress hormones before and after laparoscopic cholecystectomy with standard and low insufflation pressure, determination of ACTH and cortisol values before and after open cholecystectomy and comparison of ACTH and cortisol values between the patient sub-groups. METHODS: In a prospective study conducted between July 2016 and February 2018, we involved 110 patients which were divided into two groups: 70 patients with laparoscopic cholecystectomy (LC) and 40 patients with open cholecystectomy (OC). The first group of patients was further divided into two subgroups of 35 patients, (subgroup LC with standard and subgroup LC with low intraabdominal pressure). All patients met the preset inclusion and exclusion criteria of the study. There were no statistically significant differences in the demographic characteristics of patients between the investigated groups. The stress hormones determined were adrenocorticotropic hormone (ACTH) and cortisol. RESULTS: During the first, second and seventh day postoperative day (POD),ACTH values were significantly lower (p <0.0001) in LCLP than in LCSP and OC groups. This was also the case for comparison in LCSP and OC groups. By comparing LC and OC groups during first, the second and seventh POD, there was a significant difference (p <0.0001) in the ACTH levels. The concentration of this hormone was higher in the OC group in all three cases. The first, second and seventh POD were also statistically significant (p <0.0001) in cortisol values and between LC and OC groups there was an increase in cortisol levels in patients operated by open method. There was also a significant difference (p <0.0001) in cortisol values measured between LCLP and LCSP groups in the investigated days. Cortisol levels were higher in patients in the LCSP group. CONCLUSION: During open and laparoscopic cholecystectomy the response of the body to stress increased. The stress response of the organism during laparoscopic cholecystectomy was less than during open cholecystectomy. The stress response of the organism during laparoscopic cholecystectomy with low insufflation pressure ( 6-8mmHg) was less than during laparoscopic cholecystectomy with standard insufflation pressure (12-15mmHg).

The Effects of Music on the Life Signs of Patients in the Reanimation Unit/Recovery Room After Laparoscopic Cholecystectomy.

The purpose of the study is to determine the effects of music on the life signs of patients in the postanesthesia care unit after laparoscopic surgery. The study was carried out as a quasi-experimental model with pretest-posttest and control group in the postanesthesia care unit of a training and education hospital from March 2017 to May 2018. The sample consisted of 148 patients (74 experiment and 74 control) who were selected by the method of nonprobability sampling determined on the basis of power analysis who met the inclusion criteria. When the change in the life signs between the groups was examined, after music treatment (second measurement), there was a significant difference only in the respiratory rates (P < .05). There was a significant difference in terms of diastolic blood pressures and respiratory rates in the first admission to the clinic from the postanesthesia care unit (third measurement) (P < .05).

Comparison of single-incision and conventional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis.

BACKGROUND: Clinical studies indicate that single-incision laparoscopic cholecystectomy (SILC) has many advantages over conventional laparoscopic cholecystectomy (CLC), such as improved cosmesis, reduced postoperative pain, and shorter hospital stay. The aim of this study was to compare quality of life, body image, and cosmesis between single-incision laparoscopic and conventional laparoscopic approaches in patients undergoing cholecystectomies. SUBJECTS AND METHODS: This retrospective study between SILC and CLC and was conducted among 58 patients undergoing SILC and CLC from January 2011 to March 2013 in Turkey. After the surgery, the EuroQol-5 Dimension Questionnaire (EQ-5D™), and body image questionnaire (BIQ) were administered to the patients. RESULTS: Differences between the early and late postoperative scores in the EQ-5D were statistically significant (P < 0.001). Differences between most BIQ areas favored SILC, especially regarding cosmesis (P = 0.016); SILC patients had higher satisfaction with their scar's appearance. CONCLUSION: SILC is a promising alternative to traditional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis in selected patients.

Do preoperative depressive symptoms predict quality of life after laparoscopic cholecystectomy: A longitudinal prospective study.

OBJECTIVE: The impact of preoperative depressive symptoms on quality of life (QOL) after laparoscopic cholecystectomy (LC) remains unclear. The purpose of this study was to develop a benchmark for capturing the burden of depressive symptoms on QOL after LC and for supporting evidence-based clinical interventions for remediating these effects. METHODS: Patients diagnosed with depressive symptoms (Beck Depression Inventory score > 13) after LC (n = 336) were classified into a depressive symptoms group. Propensity score matching was then used to match them with 336 patients in a non-depressive symptoms group for all potential confounding factors. All patients completed the 36-item Short Form Health Survey (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI) at baseline and at 2 years postoperatively. The 95% confidence intervals (CIs) for differences in responsiveness estimates were derived by bootstrap estimation. RESULTS: The GIQLI results revealed that the non-depressive symptoms group had relatively stronger responses for emotional impairment (4.10, 95% CI 2.81 to 5.39) and social impairment (4.06, 95% CI 2.65 to 5.46) in comparison with the depressive symptoms group. In the SF-36, the non-depressive symptoms group also had stronger responses for role emotional (12.63, 95% CI 10.73 to 14.54), social functioning (11.25, 95% CI 9.85 to 12.65), vitality (3.81, 95% CI 2.82 to 4.81), mental health (11.97, 95% CI 10.36 to 13.56) and general health (3.84, 95% CI 2.95 to 4.75). CONCLUSIONS: Depressive symptoms complicate the management of LC patients and are associated with poorer outcomes. Because depressive symptoms are very common, further studies are needed to evaluate integrated and comprehensive approaches for assessing and treating these symptoms.

Impact of Preoperative Anxiety in Patients on Hemodynamic Changes and a Dose of Anesthetic During Induction of Anesthesia.

OBJECTIVES: Each surgical patient is preoperatively, intraoperatively and postoperatively exposed to stress. The aim of this study was to determine the existence of preoperative anxiety, and to determine its impact on hemodynamic parameters (blood pressure, heart rate) in patients and dose of anesthetics during induction of anesthesia. METHODS: A prospective clinical study conducted at the Department of Anesthesiology and Reanimation and Surgery Clinic of University Clinical Center Tuzla (UCC) in the period May 2012. to January 2015. The 80 patients were analyzed which were planned for and done an elective cholecystectomy surgery or herniectomy surgical intervention. Preoperative anxiety was measured with the help of Spielberg test and evaluation of depth of anesthesia was performed with BIS monitoring. RESULTS: The results showed that all patients had some degree of preoperative manifest anxiety. Average values of mean arterial pressure, preoperatively and after the induction of general anesthesia, differed for 15,4 mm/Hg, but were not observed significant association between Spielberg score and differences in blood pressure. Preoperative anxiety is a significant predictor of administered dose of anesthetic. Each additional score on Spielberg scale reduces the dose of anesthetic for 0,304 mg/kgTT. CONCLUSION: Adequate assessment of preoperative anxiety and undertaking of certain steps to reduce it can assist in accurately determining the required dosage of anesthetic for the introduction of general anesthesia.

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis.

BACKGROUND: The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC). METHODS: A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia. RESULTS: Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups. CONCLUSION: SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

Shortened preoperative fasting for prevention of complications associated with laparoscopic cholecystectomy: a meta-analysis.

Objective Routine fasting (12 h) is always applied before laparoscopic cholecystectomy, but prolonged preoperative fasting causes thirst, hunger, and irritability as well as dehydration, low blood glucose, insulin resistance and other adverse reactions. We assessed the safety and efficacy of a shortened preoperative fasting period in patients undergoing laparoscopic cholecystectomy. Methods We searched PubMed, Embase and Cochrane Central Register of Controlled Trials up to 20 November 2015 and selected controlled trials with a shortened fasting time before laparoscopic cholecystectomy. We assessed the results by performing a meta-analysis using a variety of outcome measures and investigated the heterogeneity by subgroup analysis. Results Eleven trials were included. Forest plots showed that a shortened fasting time reduced the operative risk and patient discomfort. A shortened fasting time also reduced postoperative nausea and vomiting as well as operative vomiting. With respect to glucose metabolism, a shortened fasting time significantly reduced abnormalities in the ratio of insulin sensitivity. The C-reactive protein concentration was also reduced by a shortened fasting time. Conclusions A shortened preoperative fasting time increases patients' postoperative comfort, improves insulin resistance, and reduces stress responses. This evidence supports the clinical application of a shortened fasting time before laparoscopic cholecystectomy.

"Contemplating the Next Maneuver": Functional Neuroimaging Reveals Intraoperative Decision-making Strategies.

OBJECTIVE: To investigate differences in the quality, confidence, and consistency of intraoperative surgical decision making (DM) and using functional neuroimaging expose decision systems that operators use. SUMMARY BACKGROUND DATA: Novices are hypothesized to use conscious analysis (effortful DM) leading to activation across the dorsolateral prefrontal cortex, whereas experts are expected to use unconscious automation (habitual DM) in which decisions are recognition-primed and prefrontal cortex independent. METHODS: A total of 22 subjects (10 medical student novices, 7 residents, and 5 attendings) reviewed simulated laparoscopic cholecystectomy videos, determined the next safest operative maneuver upon video termination (10 s), and reported decision confidence. Video paradigms either declared ("primed") or withheld ("unprimed") the next operative maneuver. Simultaneously, changes in cortical oxygenated hemoglobin and deoxygenated hemoglobin inferring prefrontal activation were recorded using Optical Topography. Decision confidence, consistency (primed vs unprimed), and quality (script concordance) were assessed. RESULTS: Attendings and residents were significantly more certain (P < 0.001), and decision quality was superior (script concordance: attendings = 90%, residents = 78.3%, and novices = 53.3%). Decision consistency was significantly superior in experts (P < 0.001) and residents (P < 0.05) than novices (P = 0.183). During unprimed DM, novices showed significant activation of the dorsolateral prefrontal cortex, whereas this activation pattern was not observed among residents and attendings. During primed DM, significant activation was not observed in any group. CONCLUSIONS: Expert DM is characterized by improved quality, consistency, and confidence. The findings imply attendings use a habitual decision system, whereas novices use an effortful approach under uncertainty. In the presence of operative cues (primes), novices disengage the prefrontal cortex and seem to accept the observed operative decision as correct.

Does preoperative depression and/or serotonin transporter gene polymorphism predict outcome after laparoscopic cholecystectomy?

OBJECTIVE: To determine whether preoperative psychological depression and/or serotonin transporter gene polymorphism are associated with poor outcomes after the common procedure of laparoscopic cholecystectomy. DESIGN: Patients undergoing laparoscopic cholecystectomy were genotyped for the serotonin transporter gene 5-HTTLPR polymorphism and assessed for psychological morbidity before and 6 weeks after surgery. The main outcome was postoperative depression; secondary outcomes included fatigue, perceived pain, quality of life and subjective perception about return to usual. RESULTS: Full genetic and psychological data were obtained from 273 out of 330 patients consented to the study (82% female). Significantly fewer people with preoperative depression (Beck Depression Inventory (BDI) score >5) had returned to employment (57% vs 86%, p<0.001) or made a full recovery (11% vs 44%, p<0.001) 6 weeks after surgery. Independent predictors for subjective return to usual after surgery included preoperative depression, body mass index and postoperative pain scores. Independent predictors of postoperative depression included preoperative antidepressant use and preoperative depression. SS genotype was associated with use of antidepressants preoperatively and higher anxiety levels after surgery. However, it was not associated with other salient postoperative psychosocial outcomes. CONCLUSIONS: Depressive psychological morbidity preoperatively, pain and body mass index appear to be important factors in predicting recovery after this common surgical procedure. There may be a place to include preoperative brief psychological screening to enable targeted support. Our results suggest that the serotonin transporter gene is unlikely to be a useful clinical predictor of outcome in this group. TRIAL REGISTRATION NUMBER: ISRCTN40219584.

Scar Pain, Cosmesis and Patient Satisfaction in Laparoscopic and Open Cholecystectomy.

OBJECTIVE: To compare patient-satisfaction, scar-pain and cosmesis between laparoscopic and open-cholecystectomy. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Khyber Teaching Hospital, Peshawar, from August 2012 to May 2014. METHODOLOGY: A total of 400 patients, who had undergone open or laparoscopic cholecystectomy in all units of the Surgical Department, were included. Data was collected on questionnaires given and read to the patients along with counselling and information regarding scar-pain using visual analog score, and satisfaction and cosmesis on a 0 - 10 scale, by a medical professional in the patients' native language. This was done postoperatively on patients' follow-up visits at 1 and 4 weeks. RESULTS: Mean scar pain score at 1 and 4 weeks postoperatively was higher for open-cholecystectomy; 4.96 ±1 and 0.96 ±1, compared to 2.24 ±0.6 and 0, respectively for laparoscopic-cholecystectomy (p < 0.001 and < 0.001). Cosmesis was higher for laparoscopic-group; 8.6 ±1.2 vs. 6.2 ±1.46 for open-cholecystectomy (p < 0.001). Patient-satisfaction was higher for laparoscopic-cholecystectomy; 9.28 ±1.5 vs. 8.32 ±2.3 for open-cholecystectomy (p < 0.001). Mean-cosmesis score was higher for laparoscopic-cholecystectomy for those younger than 40, females and unmarried. Mean patient-satisfaction score was higher for those older than 40 years who had undergone open-cholecystectomy, women who had undergone laparoscopic-cholecystectomy and for unmarried patients who had laparoscopic-cholecystectomy. CONCLUSION: Overall patient-satisfaction and cosmesis scoring was higher for laparoscopic-cholecystectomy especially among females, unmarried and younger than 40 years. Patients of 40 years and older had greater satisfaction scoring for open-cholecystectomy. Therefore, laparoscopic-cholecystectomy should be favoured in females and unmarried patients and those younger than 40 years.

Surgical decision making in a teaching hospital: a linguistic analysis.

BACKGROUND: The aim of the study was to gain insight in the involvement of non-operating surgeons in intraoperative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work. METHOD: Eleven laparoscopic cholecystectomies performed by consultant surgeons and specialty trainees at a London teaching hospital were audio and video recorded. Talk among the surgical team was transcribed and subjected to linguistic analysis, in conjunction with observational analysis of the video material, sequentially marking the unfolding operation. RESULTS: Two components of decision making were identified, participation and rationalization. Participation refers to the degree to which agreement was sought within the surgical team prior to clipping the cystic duct. Rationalization refers to the degree to which the evidential grounds for clipping and cutting were verbalized. CONCLUSION: The decision to clip and cut the cystic duct was jointly made by members of the surgical team, rather than a solitary surgeon in the majority of cases, involving verbal explication of clinical reasoning and verbal agreement. The extent of joint decision making appears to have been mitigated by two factors: trainee's level of training and duration of the case.

Biological inflammatory markers mediate the effect of preoperative pain-related behaviours on postoperative analgesics requirements.

BACKGROUND: The predictive value of an individual's attitude towards painful situations and the status of his immune system for postoperative analgesic requirements are not well understood. These may help the clinician to anticipate individual patient's needs. METHODS: Sixty patients, who underwent a laparoscopic cholecystectomy under standardised general anaesthesia, were included. The total analgesic requirements during the first 48 h were the primary endpoint (unitary dosage, UD). The individual's attitude towards imaginary painful situations was measured with the Situational Pain Scale (SPS). The emotional status was assessed by the Hospital Anxiety and Depression Scale (HADS) and the inflammatory status by the neutrophil-to-lymphocyte ratio (NLR). RESULTS: Univariate analyses revealed a significant association between UD and SPS, HADS and NLR. A negative relationship between SPS and NLR (NLR = 0.820-0.180*SPS;R(2) = 0.211;P < 0.001) and a positive relationship between SPS and HADS (HADS = 14.8 + 1.63*SPS; R(2) = 0.159;P = 0.002) were observed. A multiple linear regression analysis showed that the contribution of NLR to the UD was the most effective. A mediation analysis showed a complete mediation of the effect of SPS on UD (R(2) = 0.103;P = 0.012), by the NLR (SPS on NLR: R(2) = 0.211;P = <0.001), the HADS (SPS on HADS: R(2) = 0.159;P = 0.002). The variance in UD explained by the SPS was indirect and amounts to 46% through NLR and to 34% through HADS. CONCLUSIONS: In this series, preoperative pain-related attitudes (SPS) were associated with the postoperative analgesic requirements (UD) after a cholecystectomy. Eighty per cent of this effect was mediated by the HADS and the NLR.

Cosmesis and Body Image in Patients Undergoing Single-port Versus Conventional Laparoscopic Cholecystectomy: A Multicenter Double-blinded Randomized Controlled Trial (SPOCC-trial).

OBJECTIVE: To evaluate cosmesis, body image, pain, and quality of life (QoL) after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy (4PLC). BACKGROUND: The impact of SPLC on improving cosmesis, body image, pain, and QoL has not been evaluated in double-blinded randomized controlled trials (RCT). This approach therefore remains controversial. METHODS: Between October 2011 and February 2014, 110 patients from 2 centers were randomly assigned to SPLC (n = 55) or 4PLC (n = 55). Primary endpoints were a validated cosmesis (3-24 points) and body image (5-20 points) score after 3 and 12 months. Secondary endpoints included operative duration, postoperative pain, complications, QoL, and length of hospital stay. Patients, physicians, and nurses were blinded until the seventh postoperative day. RESULTS: Demographics were equally distributed between both groups (mean age: 46 years, SD: 14, 62 females, 34 males). The SPLC-group showed superior mean cosmesis and body image compared with the 4PLC-group at 12-weeks (21 vs 16, P < 0.001 and 5 vs 6, P = 0.013, respectively) and at 1-year (24 vs 16, P < 0.001 and 5 vs 6, P < 0.017, respectively). Operation duration was longer in the SPLC-group (mean 101 vs 90 minutes, p = 0.031). Although postoperative pain was less in the SPLC-group (mean VAS 1 vs 2, p = 0.005), there were no differences in complications, and length of hospital-stay. CONCLUSIONS: This is the first multicenter double-blinded RCT reporting superior short- and long-term cosmetic and body image, postoperative pain, and QoL in SPLC compared with 4PLC. Although cost-effectiveness is still a subject of ongoing debate, SPLC should be offered to patients undergoing surgery for benign gallbladder disease.

Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy.

BACKGROUND: Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy. STUDY DESIGN: Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items. RESULTS: A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 [range 8 to 14]). One hundred eight cognitive elements (35 [32%] related to situation awareness, 47 [44%] involving decision-making, and 26 [24%] action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 [32%]), decision-making (49 [65%]), or either one (61 [81%]). CONCLUSIONS: This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety.

Evaluation of Patient Feedback following Laparoscopic Cholecystectomy based on Information Described in the Informed Consent form Developed by the Association of Polish Surgeons.

UNLABELLED: The cholecystectomy procedure is the most routinely performed intervention in general surgery. The current international gold standard is via the laparoscopic approach. It is a safe, minimally-invasive procedure; however, it is associated with complications in 1% of cases. The aim of the study was to analyze patient feedback, by means of a survey, to determine how much knowledge patients possessed about their disease state and proposed surgical intervention, based primarily on information contained within the informed consent form developed by the Association of Polish Surgeons. MATERIAL AND METHODS: This study involved the participation of 51 patients who underwent laparoscopic cholecystectomy, indicated by a diagnosis of gallstones, in the years 2014 and 2015. RESULTS: Despite having signed the informed consent form, there was considerable variation among the responses given to the survey by the 51 patients in this study. Some patients' responses were tangential to the questions asked; many patients did not respond to any of the sub points. CONCLUSIONS: Given that this study is based on a small sample size of patients, it must be presumed that the process by which the patient declares his or her informed consent requires further consideration with respect to the means by which it is obtained. The authors of this study thus recommend that multimedia resources be harnessed as part of the process of obtaining the informed consent of patients prior to surgical intervention.