1
|
Wakasa Y, Hakamada K, Morohashi H, Kanno T, Tadano K, Kawashima K, Ebihara Y, Oki E, Hirano S, Mori M. Ensuring communication redundancy and establishing a telementoring system for robotic telesurgery using multiple communication lines. J Robot Surg 2024; 18:9. [PMID: 38206522 PMCID: PMC10784335 DOI: 10.1007/s11701-023-01792-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024]
Abstract
Assuring communication redundancy during the interruption and establishing appropriate teaching environments for local surgeons are essential to making robotic telesurgery mainstream. This study analyzes robotic telesurgery with telementoring using standard domestic telecommunication carriers. Can multiple carriers guarantee redundancy with interruptions? Three commercial optical fiber lines connected Hirosaki University and Mutsu General Hospitals, 150 km apart. Using Riverfield, Inc. equipment, Hirosaki had a cockpit, while both Mutsu used both a cockpit and a surgeon's console. Experts provided telementoring evaluating 14 trainees, using objective indices for operation time and errors. Subjective questionnaires addressed image quality and surgical operability. Eighteen participants performed telesurgery using combined lines from two/three telecommunication carriers. Manipulation: over 30 min, lines were cut and restored every three minutes per task. Subjects were to press a switch when noticing image quality or operability changes. Mean time to task completion was 1510 (1186-1960) seconds: local surgeons alone and 1600 (1152-2296) seconds for those under remote instructor supervision, including expert intervention time. There was no significant difference (p = 0.86). The mean error count was 0.92 (0-3) for local surgeons and 0.42 (0-2) with remote instructors. Image quality and operability questionnaires found no significant differences. Results communication companies A, B, and C: the A/B combination incurred 0.17 (0-1) presses of the environment change switch, B/C had 0, and C/A received 0.67 (0-3), showing no significant difference among provider combinations. Combining multiple communication lines guarantees communication redundancy and enables robotic telementoring with enhanced communication security.
Collapse
Affiliation(s)
- Yusuke Wakasa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho Hirosaki, Aomori, 036-8562, Japan
| | - Kenichi Hakamada
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan.
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho Hirosaki, Aomori, 036-8562, Japan.
| | - Hajime Morohashi
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho Hirosaki, Aomori, 036-8562, Japan
| | | | | | - Kenji Kawashima
- Department of Information Physics and Computing School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yuma Ebihara
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Eiji Oki
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Satoshi Hirano
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaki Mori
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Tokai University School of Medicine, Isehara, Japan
| |
Collapse
|
2
|
Morohashi H, Hakamada K, Kanno T, Tadano K, Kawashima K, Takahashi Y, Ebihara Y, Oki E, Hirano S, Mori M. Construction of redundant communications to enhance safety against communication interruptions during robotic remote surgery. Sci Rep 2023; 13:10831. [PMID: 37402741 DOI: 10.1038/s41598-023-37730-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/27/2023] [Indexed: 07/06/2023] Open
Abstract
It is important to ensure the redundancy of communication during remote surgery. The purpose of this study is to construct a communication system that does not affect the operation in the event of a communication failure during telesurgery. The hospitals were connected by two commercial lines, a main line and a backup line, with redundant encoder interfaces. The fiber optic network was constructed using both guaranteed and best-effort lines. The surgical robot used was from Riverfield Inc. During the observation, a random shutdown and restoration process of either line was conducted repeatedly. First, the effects of communication interruption were investigated. Next, we performed a surgical task using an artificial organ model. Finally, 12 experienced surgeons performed operations on actual pigs. Most of the surgeons did not feel the effects of the line interruption and restoration on still and moving images, in artificial organ tasks, and in pig surgery. During all 16 surgeries, a total of 175-line switches were performed, and 15 abnormalities were detected by the surgeons. However, there were no abnormalities that coincided with the line switching. It was possible to construct a system in which communication interruptions would not affect the surgery.
Collapse
Affiliation(s)
- Hajime Morohashi
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kenichi Hakamada
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan.
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | | | | | - Kenji Kawashima
- Department of Information Physics and Computing School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yoshiya Takahashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuma Ebihara
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eiji Oki
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Satoshi Hirano
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masaki Mori
- Committee for Promotion of Remote Surgery Implementation, Japan Surgical Society, Tokyo, Japan
- Tokai University School of Medicine, Isehara, Japan
| |
Collapse
|
3
|
Takahashi Y, Hakamada K, Morohashi H, Akasaka H, Ebihara Y, Oki E, Hirano S, Mori M. Reappraisal of telesurgery in the era of high-speed, high-bandwidth, secure communications: Evaluation of surgical performance in local and remote environments. Ann Gastroenterol Surg 2022; 7:167-174. [PMID: 36643359 PMCID: PMC9831893 DOI: 10.1002/ags3.12611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/27/2022] [Indexed: 01/18/2023] Open
Abstract
Aim Communication and video transmission delays negatively affect telerobotic surgery. Since latency varies by communication environment and robot, to realize remote surgery, both must perform well. This study aims to examine the feasibility of telerobotic surgery by validating the communication environment and local/remote robot operation, using secure commercial lines and newly developed robots. Methods Hirosaki University and Mutsu General Hospital, 150 km apart, were connected via a Medicaroid surgical robot. Ten surgeons performed a simple task remotely using information encoding and decoding. The required bandwidth, delay time, task completion time, number of errors, and image quality were evaluated. Next, 11 surgeons performed a complex task using gallbladder and intestinal models in local/remote environments; round trip time (RTT), packet loss, time to completion, operator fatigue, operability, and image were observed locally and remotely. Results Image quality was not so degraded as to affect remote robot operation. Median RTT was 4 msec (2-12), and added delay was 29 msec. There was no significant difference in accuracy or number of errors for cholecystectomy, intestinal suturing, completion time, surgeon fatigue, or image evaluation. Conclusion The fact that remote surgery succeeded equally to local surgery showed that this system has the necessary elemental technology for widespread social implementation.
Collapse
Affiliation(s)
- Yoshiya Takahashi
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan,Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan,Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan
| | - Hajime Morohashi
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan,Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan
| | - Harue Akasaka
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan,Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan
| | - Yuma Ebihara
- Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan,Department of Gastroenterological Surgery IIHokkaido University Faculty of MedicineSapporoJapan
| | - Eiji Oki
- Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan,Department of Surgery and ScienceKyushu UniversityFukuokaJapan
| | - Satoshi Hirano
- Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan,Department of Gastroenterological Surgery IIHokkaido University Faculty of MedicineSapporoJapan
| | - Masaki Mori
- Committee for Promotion of Remote Surgery ImplementationJapan Surgical SocietyTokyoJapan,Tokai University School of MedicineIseharaJapan
| |
Collapse
|
4
|
Ghaderi I, Korovin L, Farrell TM. Preparation for Challenging Cases: What Differentiates Expert From Novice Surgeons? JOURNAL OF SURGICAL EDUCATION 2021; 78:450-461. [PMID: 32958418 DOI: 10.1016/j.jsurg.2020.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The study of expert performance provides a rich field for exploration in the surgical literature. This study aimed to examine the difference between expert and novice surgeons in their preparation for challenging cases. DESIGN Expert (attending) and novice (postgraduate-year 2) surgeons were presented two cases of complicated cholecystitis and were asked how they would prepare, what they would expect to encounter intraoperatively, and how they would deal with these challenges. Their responses were recorded, transcribed verbatim and analyzed using thematic analysis. SETTING Academic teaching hospitals. PARTICIPANTS Two group of expert and novice surgeons. RESULTS Nine experts and eleven novices from two academic centers participated. The majority of novices focused on patient history, work-up, preoperative optimization, anatomy, and anticipation of intraoperative challenges. In addition to the patient's presentation and preoperative optimization, most experts' thoughts were directed toward preparation for surgery (level of urgency, required skills in surgical team, case difficulty, and risk of conversion to open). Experts would involve the patient in the decision-making and were more likely to communicate with the operating room team. While novices attempted to predict challenges depending on gallbladder condition and intra-abdominal adhesions, the experts highlighted the importance of various elements of the operative field, the detail of the technique and possible challenges, and their troubleshooting plans. Regarding operative planning to address anticipated challenges, novices would tailor their plan to patient characteristics and verbalized an analytical "if-then" approach for all possibilities they might encounter. Experts would start with their standard technique regardless of case complexity and would deal with contingencies as they arise. Safety was a critical part of expert surgeons' plans. CONCLUSIONS Novices mostly conveyed descriptive knowledge based on presented facts while experts demonstrated an ability to paint a richer mental image of possible future events by creating comprehensive anticipation of the operative field. Further studies are needed to validate the results of this study.
Collapse
|
5
|
The Effect of Technical Problems on the Operation Process in Pediatric Laparoscopy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:110-113. [PMID: 32377067 PMCID: PMC7199834 DOI: 10.14744/semb.2018.74436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/05/2018] [Indexed: 11/20/2022]
Abstract
Objectives: The aim of this study was to determine the technical problems in pediatric laparoscopic surgery and to evaluate its results. Methods: The technical problems encountered in 30 laparoscopic operations performed between 3 November 2012 and 31 December 2017 were retrospectively analyzed. Results: The technical problems experienced in 30 laparoscopic surgeries were analyzed. There were 6 splenectomies, 15 appendectomies, 1 hernioplasty, 2 ovarian cyst excisions, 4 cholecystectomies, 1 intra-abdominal exploration of the testes, and 1 varicocele surgery. The technical errors included instrument failure in 10, human errors in 8, device problems in 12, and multiple problems in 2 cases. In 5 patients, we switched to open surgery. Conclusion: Technical problems prolong the operation, and cause a conversion to open surgery. In order to solve these problems, it is necessary to register and report these problems and take the necessary preventive measures.
Collapse
|
6
|
Irfan W, Sheahan C, Mitchell EL, Sheahan MG. The pathway to a national vascular skills examination and the role of simulation-based training in an increasingly complex specialty. Semin Vasc Surg 2019; 32:48-67. [DOI: 10.1053/j.semvascsurg.2018.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
7
|
Simulation in Vascular Surgery. COMPREHENSIVE HEALTHCARE SIMULATION: SURGERY AND SURGICAL SUBSPECIALTIES 2019. [DOI: 10.1007/978-3-319-98276-2_26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
8
|
Korovin LN, Farrell TM, Hsu CH, White M, Ghaderi I. Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis. Am J Surg 2018; 219:340-345. [PMID: 30591181 DOI: 10.1016/j.amjsurg.2018.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy. METHODS A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method. RESULTS Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity. CONCLUSIONS This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.
Collapse
Affiliation(s)
| | | | | | | | - Iman Ghaderi
- Department of Surgery, University of Arizona, USA.
| |
Collapse
|
9
|
What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance. Ann Surg 2017; 265:255-267. [PMID: 27611618 DOI: 10.1097/sla.0000000000001962] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. BACKGROUND Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. METHODS Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. RESULTS A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. CONCLUSIONS This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.
Collapse
|
10
|
Liu R, Zhang X, Zhang H. Web-video-mining-supported workflow modeling for laparoscopic surgeries. Artif Intell Med 2016; 74:9-20. [PMID: 27964803 DOI: 10.1016/j.artmed.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 11/11/2016] [Accepted: 11/13/2016] [Indexed: 10/20/2022]
Abstract
MOTIVATION As quality assurance is of strong concern in advanced surgeries, intelligent surgical systems are expected to have knowledge such as the knowledge of the surgical workflow model (SWM) to support their intuitive cooperation with surgeons. For generating a robust and reliable SWM, a large amount of training data is required. However, training data collected by physically recording surgery operations is often limited and data collection is time-consuming and labor-intensive, severely influencing knowledge scalability of the surgical systems. OBJECTIVE The objective of this research is to solve the knowledge scalability problem in surgical workflow modeling with a low cost and labor efficient way. METHODS A novel web-video-mining-supported surgical workflow modeling (webSWM) method is developed. A novel video quality analysis method based on topic analysis and sentiment analysis techniques is developed to select high-quality videos from abundant and noisy web videos. A statistical learning method is then used to build the workflow model based on the selected videos. To test the effectiveness of the webSWM method, 250 web videos were mined to generate a surgical workflow for the robotic cholecystectomy surgery. The generated workflow was evaluated by 4 web-retrieved videos and 4 operation-room-recorded videos, respectively. RESULTS The evaluation results (video selection consistency n-index ≥0.60; surgical workflow matching degree ≥0.84) proved the effectiveness of the webSWM method in generating robust and reliable SWM knowledge by mining web videos. CONCLUSION With the webSWM method, abundant web videos were selected and a reliable SWM was modeled in a short time with low labor cost. Satisfied performances in mining web videos and learning surgery-related knowledge show that the webSWM method is promising in scaling knowledge for intelligent surgical systems.
Collapse
Affiliation(s)
- Rui Liu
- Department of Mechanical Engineering, Colorado School of Mines, Golden, CO 80401, USA
| | - Xiaoli Zhang
- Department of Mechanical Engineering, Colorado School of Mines, Golden, CO 80401, USA.
| | - Hao Zhang
- Department of Electrical Engineering & Computer Science, Colorado School of Mines, Golden, CO 80401,USA
| |
Collapse
|
11
|
Husslein H, Shirreff L, Shore EM, Lefebvre GG, Grantcharov TP. The Generic Error Rating Tool: A Novel Approach to Assessment of Performance and Surgical Education in Gynecologic Laparoscopy. JOURNAL OF SURGICAL EDUCATION 2015; 72:1259-65. [PMID: 26111823 DOI: 10.1016/j.jsurg.2015.04.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 04/14/2015] [Accepted: 04/29/2015] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Global rating scales are commonly used to rate surgeons' skill level. However, these tools lack granularity required for specific skill feedback. Recently, an alternative framework has been developed that is designed to measure technical errors during laparoscopy. The purpose of the present study was to gather validity evidence for the Generic Error Rating Tool (GERT) in gynecologic laparoscopy. DESIGN Video recordings of total laparoscopic hysterectomies were analyzed by 2 blinded reviewers using the GERT and the Objective Structured Assessment of Technical Skills (OSATS) scale. Several sources of validity were examined according to the unitary framework of validity. Main outcomes were interrater and intrarater reliability regarding total number of errors and events. Further, surgeons were grouped according to OSATS scores (OSATS ≥ 28 = high performers and OSATS < 28 = low performers), and the number of errors and events was compared between groups. Correlation analysis between GERT and OSATS scores was performed. Lastly, error distribution within procedure steps was explored and compared between high- and low-performing surgeons. SETTING University teaching hospital. PARTICIPANTS A total of 20 anonymized video recordings of total laparoscopic hysterectomies. RESULTS Interrater and intrarater reliability was high (intraclass correlation coefficient >0.95) for total number of errors and events. Low performers made significantly more errors than high performers did (median = 49.5 [interquartile range: 34.5-66] vs median = 31 [interquartile range: 16.75-35.25], p = 0.002). There was a significant negative correlation between individual OSATS scores and total number of errors (Spearman ρ = -0.76, p < 0.001, and ρ = -0.88, p < 0.001, for raters 1 and 2, respectively). Error distribution varied between operative steps, and low performers made more errors in some steps, but not in others. CONCLUSION GERT allows for objective and reproducible assessment of technical errors during gynecologic laparoscopy and could be used for performance analysis and personalized surgical education and training.
Collapse
Affiliation(s)
- Heinrich Husslein
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria.
| | - Lindsay Shirreff
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eliane M Shore
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Guylaine G Lefebvre
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- Division of General Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Madani A, Watanabe Y, Feldman LS, Vassiliou MC, Barkun JS, Fried GM, Aggarwal R. Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy. J Am Coll Surg 2015; 221:931-940.e8. [DOI: 10.1016/j.jamcollsurg.2015.07.450] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/18/2015] [Accepted: 07/27/2015] [Indexed: 01/06/2023]
|
13
|
Bonrath EM, Gordon LE, Grantcharov TP. Characterising 'near miss' events in complex laparoscopic surgery through video analysis. BMJ Qual Saf 2015; 24:516-21. [PMID: 25947330 DOI: 10.1136/bmjqs-2014-003816] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/17/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes. OBJECTIVE Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures. METHODS Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases. RESULTS Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were 'inadequate use of force/distance (too much)' (n=20, 30%) and 'inadequate visualisation' during grasping/dissecting (n=6, 9%), 'inadequate use of force/distance (too much)' using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively. CONCLUSIONS Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons' understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.
Collapse
Affiliation(s)
- Esther M Bonrath
- Division of General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lauren E Gordon
- Division of General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | | |
Collapse
|
14
|
Watanabe Y, Bilgic E, Lebedeva E, McKendy KM, Feldman LS, Fried GM, Vassiliou MC. A systematic review of performance assessment tools for laparoscopic cholecystectomy. Surg Endosc 2015; 30:832-44. [PMID: 26092014 DOI: 10.1007/s00464-015-4285-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/23/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple tools are available to assess clinical performance of laparoscopic cholecystectomy (LC), but there are no guidelines on how best to implement and interpret them in educational settings. The purpose of this systematic review was to identify and critically appraise LC assessment tools and their measurement properties, in order to make recommendations for their implementation in surgical training. METHODS A systematic search (1989-2013) was conducted in MEDLINE, Embase, Scopus, Cochrane, and grey literature sources. Evidence for validity (content, response process, internal structure, relations to other variables, and consequences) and the conditions in which the evidence was obtained were evaluated. RESULTS A total of 54 articles were included for qualitative synthesis. Fifteen technical skills and two non-technical skills assessment tools were identified. The 17 tools were used for either: recorded procedures (nine tools, 60%), direct observation (five tools, 30%), or both (three tools, 18%). Fourteen (82%) tools reported inter-rater reliability and one reported a Generalizability Theory coefficient. Nine (53%) had evidence for validity based on clinical experience and 11 (65%) compared scores to other assessments. Consequences of scores, educational impact, applications to residency training, and how raters were trained were not clearly reported. No studies mentioned cost. CONCLUSIONS The most commonly reported validity evidence was inter-rater reliability and relationships to other known variables. Consequences of assessments and rater training were not clearly reported. These data and the evidence for validity should be taken into consideration when deciding how to select and implement a tool to assess performance of LC, and especially how to interpret the results.
Collapse
Affiliation(s)
- Yusuke Watanabe
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada.
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
| | - Elif Bilgic
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada
| | - Ekaterina Lebedeva
- The Henry K.M. De Kuyper Education Centre, McGill University Health Centre, Montreal, QC, Canada
| | - Katherine M McKendy
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada
| | - Gerald M Fried
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada
| | - Melina C Vassiliou
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650, Cedar Avenue, L9. 316, Montreal, QC, H3G 1A4, Canada.
| |
Collapse
|
15
|
Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP. International consensus on safe techniques and error definitions in laparoscopic surgery. Surg Endosc 2013; 28:1535-44. [DOI: 10.1007/s00464-013-3348-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/02/2013] [Indexed: 01/22/2023]
|
16
|
Bharathan R, Setchell T, Miskry T, Darzi A, Aggarwal R. Gynecologic endoscopy skills training and assessment: review. J Minim Invasive Gynecol 2013; 21:28-43. [PMID: 23933352 DOI: 10.1016/j.jmig.2013.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 07/30/2013] [Accepted: 07/30/2013] [Indexed: 11/19/2022]
Abstract
Training in and assessment of endoscopic skills is currently undergoing a period of evolution. Several recognized factors driving this evolution include working pattern, training opportunities, cost, and patient safety. In addition, the need to continuously monitor competence is punctuated by the rapid technologic changes and rising consumer expectation. These challenges present an opportunity to positively enhance the learning and performance of surgical practice.
Collapse
Affiliation(s)
- Rasiah Bharathan
- Department of Surgery and Cancer, Imperial College, St. Mary's Hospital, London; Nuffield Department of Obstetrics and Gynecology, Oxford University Hospitals NHS Trust, Oxford, UK.
| | - Thomas Setchell
- Department of Obstetrics and Gynecology, Women's Centre, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London
| | - Tariq Miskry
- Department of Obstetrics and Gynecology, Women's Centre, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College, St. Mary's Hospital, London
| | - Rajesh Aggarwal
- Department of Surgery and Cancer, Imperial College, St. Mary's Hospital, London; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
17
|
Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP. Defining technical errors in laparoscopic surgery: a systematic review. Surg Endosc 2013; 27:2678-91. [PMID: 23436086 DOI: 10.1007/s00464-013-2827-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/07/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Technical errors, a distinct subcomponent of surgical proficiency, have a significant impact on patient safety and clinical outcomes. To date, only a few studies have been designed to describe and evaluate these errors. This review was performed to assess technical errors described in laparoscopic surgery. METHODS A literature search of Medline, Cochrane, EMBASE, and OVID databases (1946-2012, week 14) using the terms "technical/medical error," "technical skill," and "adverse event" in combination with the terms "laparoscopy/laparoscopic surgery" was conducted. English language peer review articles with a description of technical errors were included. Opinion papers, reviews, and articles not addressing laparoscopic surgery were excluded. RESULTS The search returned 2,282 articles. Application of the inclusion criteria reduced the number of articles to 21. Of these 21 articles, 14 (67 %) were observational studies, 3 (14 %) were randomized trials, 2 (10 %) were prospective interventional studies, and 2 (10 %) were retrospective analyses. Eight articles (38 %) applied error analysis as an approach to determine error rates within routine procedures. The remaining 13 articles (62 %) used the assessment of errors to describe and quantify surgical skill in an educational setting. CONCLUSIONS A number of approaches for the assessment of surgical technical errors exist. The error definitions vary greatly, making a comparison of error rates between groups impossible. Complexity of scale design and subjectivity in ratings have resulted in limited use of these scores outside the experimental setting. To facilitate error analysis as a self-assessment method of continuous learning and quality control, further research and better tools are required.
Collapse
Affiliation(s)
- Esther M Bonrath
- Division of General Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | | | | | | |
Collapse
|
18
|
Technical skill training improves the ability to learn. Surgery 2011; 149:1-6. [DOI: 10.1016/j.surg.2010.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 03/12/2010] [Indexed: 11/23/2022]
|
19
|
Bingener J, Boyd T, Van Sickle K, Jung I, Saha A, Winston J, Lopez P, Ojeda H, Schwesinger W, Anastakis D. Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic suturing training. Am J Surg 2008; 195:179-82. [DOI: 10.1016/j.amjsurg.2007.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Revised: 11/05/2007] [Accepted: 11/05/2007] [Indexed: 01/22/2023]
|
20
|
Neequaye SK, Aggarwal R, Van Herzeele I, Darzi A, Cheshire NJ. Endovascular skills training and assessment. J Vasc Surg 2007; 46:1055-64. [DOI: 10.1016/j.jvs.2007.05.041] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 05/20/2007] [Indexed: 10/22/2022]
|
21
|
Aggarwal R, Grantcharov T, Moorthy K, Milland T, Papasavas P, Dosis A, Bello F, Darzi A. An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room. Ann Surg 2007; 245:992-9. [PMID: 17522527 PMCID: PMC1876956 DOI: 10.1097/01.sla.0000262780.17950.e5] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the use of a synchronized video-based motion tracking device for objective, instant, and automated assessment of laparoscopic skill in the operating room. SUMMARY BACKGROUND DATA The assessment of technical skills is fundamental to recognition of proficient surgical practice. It is necessary to demonstrate the validity, reliability, and feasibility of any tool to be applied for objective measurement of performance. METHODS Nineteen subjects, divided into 13 experienced (performed >100 laparoscopic cholecystectomies) and 6 inexperienced (performed <10 LCs) surgeons completed LCs on 53 patients who all had a diagnosis of biliary colic. Each procedure was recorded with the ROVIMAS video-based motion tracking device to provide an objective measure of the surgeon's dexterity. Each video was also rated by 2 experienced observers on a previously validated operative assessment scale. RESULTS There were significant differences for motion tracking parameters between the 2 groups of surgeons for the Calot triangle dissection part of procedure for time taken (P = 0.002), total path length (P = 0.026), and number of movements (P = 0.005). Both motion tracking and video-based assessment displayed intertest reliability, and there were good correlations between the 2 modes of assessment (r = 0.4 to 0.7, P < 0.01). CONCLUSIONS An instant, objective, valid, and reliable mode of assessment of laparoscopic performance in the operating room has been defined. This may serve to reduce the time taken for technical skills assessment, and subsequently lead to accurate and efficient audit and credentialing of surgeons for independent practice.
Collapse
Affiliation(s)
- Rajesh Aggarwal
- Department of Biosurgery & Surgical Technology, Imperial College London, St. Mary's Hospital, Praed Street, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Verdaasdonk EGG, Stassen LPS, van der Elst M, Karsten TM, Dankelman J. Problems with technical equipment during laparoscopic surgery. An observational study. Surg Endosc 2006; 21:275-9. [PMID: 17122973 DOI: 10.1007/s00464-006-0019-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 05/25/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study was designed to investigate the incidence of technical equipment problems during laparoscopic procedures. METHODS A video-capturing system was used, consisting of an analog video recorder with three camera image inputs and a microphone. Problems with all technical equipment used by the surgical team, such as the insufflator, diathermy apparatus, monitors, light source, camera and camera unit, endoscope, suction devices, and instruments, were registered. RESULTS In total, 30 procedures were randomly videotaped. In 87% (26/30) of the procedures, one or more incidents with technical equipment (49 incidents) or instruments (9 incidents) occurred. In 22 of those incidents (45%) the technical equipment was not correctly positioned or not present at all; in the other 27 (55%), the equipment malfunctioned as a result of a faulty connection (9), a defect (5), or the wrong setting of the equipment (3). In 10 (20%) cases the exact cause of equipment malfunctioning was unclear. CONCLUSIONS The incidence of problems with laparoscopic technical equipment is high. To prevent such problems, improvement and standardization of equipment is needed, combined with the incorporation of checklist use before the start of a surgical procedure. Future research should be aimed at development, implementation, and evaluation of these measures into the operating room.
Collapse
Affiliation(s)
- E G G Verdaasdonk
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands.
| | | | | | | | | |
Collapse
|
23
|
Sarker SK, Chang A, Vincent C, Darzi SAW. Development of assessing generic and specific technical skills in laparoscopic surgery. Am J Surg 2006; 191:238-44. [PMID: 16442953 DOI: 10.1016/j.amjsurg.2005.07.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 07/29/2005] [Accepted: 07/29/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Assessing live laparoscopic surgery using structured methodology is still in its infancy; however, it removes bias and subjectivity. We critique a new assessment tool for technical skills in laparoscopic surgery. METHODS A hierarchical task analysis was done for laparoscopic cholecystectomy (LC), and a global assessment for generic and specific technical skills for LC was developed. Two experienced surgeons with >12 years of postgraduate experience assessed 50 full-length LC operations blindly and independently. RESULTS Five consultant/attending and 4 registrar/resident surgeons were recruited. Interrater reliability was k = 0.86 and k = 0.84 (P < .05) for generic and specific technical skills, respectively. Mean time for consultants was 32 minutes (range 15 to 70) and for registrars was 53 minutes (range 20 to 90). Parametric Student t test analysis was significant for time between the 2 groups, P < .05. Nonparametric analysis of variance between the 2 groups for generic and specific technical skills was significant at P < .05. CONCLUSIONS This assessment tool for live laparoscopic surgery may have face, content, concurrent, construct, and predictive validities for generic and specific technical skills. We aim to continue the study and expand assessment to other surgical techniques.
Collapse
Affiliation(s)
- Sudip K Sarker
- Clinical Safety Research Unit, Department of Surgical Oncology and Technology, South Wharf Rd., 10th Floor QEQM Bldg., St Mary's Hospital, London, UK.
| | | | | | | |
Collapse
|
24
|
Sarker SK, Hutchinson R, Chang A, Vincent C, Darzi AW. Self-appraisal hierarchical task analysis of laparoscopic surgery performed by expert surgeons. Surg Endosc 2006; 20:636-40. [PMID: 16446987 DOI: 10.1007/s00464-005-0312-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 10/25/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Evaluation of technical skill is notoriously difficult because of the subjectivity and time-consuming expert analysis. No ongoing evaluation scheme exists to assess the continuing competency of surgeons. This study examined whether surgeons' self-assessment accurately reflects their actual surgical technique. METHODS Hierarchical task analysis (HTA) of laparoscopic cholecystectomy was constructed. Ten expert surgeons were asked to modify the HTA for their own technique. The HTAs of these surgeons then were compared with their actual operations, which had been recorded and assessed by two observers. RESULTS A total of 40 operations were assessed. All the gallbladders subjected to surgery were classified as grades 1 to 3. The mean interrater reliability for the two observers had a k value of 0.84 (p < 0.05), and the mean intrarater reliability between surgeons and observers had a k value of 0.79 (p < 0.05). CONCLUSIONS Surgeons' self-evaluation is accurate for technical skills aspects of their operations. This study demonstrates that self-appraisal using HTA is feasible, accurate, and practical. The authors aim to increase the numbers in their study and also to recruit residents.
Collapse
Affiliation(s)
- S K Sarker
- Department of Surgical Oncology and Technology, St Mary's Hospital, Imperial College London, London, W2 1NY, United Kingdom.
| | | | | | | | | |
Collapse
|