Is laparoscopic cholecystectomy a mature operative technique?

Defining the technical skills of teamwork in surgery

Developments in surgical technology and procedure have accelerated and altered the work carried out in the operating theatre/room, but team modelling and training have not co-evolved. Evidence suggests that team structure and role allocation are sometimes unclear and contentious, and coordination and communication are not fully effective. To improve teamwork, clinicians need models that specify team resources, structure, process and tasks. They also need measures to assess performance and methods to train teamwork strategically. An effective training strategy might be to incorporate teamwork with other technical skills training in simulation. However, the measures employed for enhancing teamwork in training and practice will need to vary in their object of analysis, level of technical specificity, and system scope.

Measuring intra-operative interference from distraction and interruption observed in the operating theatre

An observational tool was developed to record distraction and interruption in the operating theatre during surgery. Observed events were assigned to pre-defined categories and rated in relation to the level of team involvement - the sum of which was treated as a measure of intra-operative interference. Many events (0.29 +/- 0.02 per min) were observed and rated in 50 general operations sampled from a single operating theatre. The rating of individual events (r(s) = 0.65) and of cases (r(s) = 0.89) correlated between independent observers. Interference levels (1.04 +/- 0.07/min) also correlated with door opening frequency (0.68 +/- 0.03/min) (r = 0.47, p < 0.001). Some sources of interference were intrinsic to the work of the surgical team, including equipment, procedure and environment, while others were extraneous, including bleepers, phone calls and external staff. The findings highlight the need to further develop measures of interference, to assess its variation, intensity and its effect on surgical team performance.

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES

To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials.

METHODS

Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect.

RESULTS

Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period.

CONCLUSIONS

Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.