International consensus on safe techniques and error definitions in laparoscopic surgery

The clinical significance of intraoperative adverse events in laparoscopic radical hysterectomies for early-stage cervical cancer

OBJECTIVE

Surgical quality plays a vital role in the treatment of malignant tumors. We investigated the classification of intraoperative adverse events (iAE) (ClassIntra) in relation to the surgical quality control of laparoscopic radical hysterectomies.

METHODS

A prospective cohort of 195 patients who had undergone laparoscopic radical hysterectomies for early stage cervical cancer between July 2019 and July 2021 was enrolled. Participants were classified into either an iAE or non-iAE groups in accordance with their intraoperative status. Surgical outcomes, patient satisfaction, and quality of life were compared between the two groups.

RESULTS

Overall, 48 (24.6%) patients experienced 71 iAE. The iAE group was associated with significantly longer operative times (mean: 270 vs. 245 min, P < 0.001), greater blood loss (mean: 215 vs. 120 mL, P < 0.001), and longer postoperative hospital stays (median: 16 vs. 11 days). Larger tumors and poor technical performance significantly increased the risk of iAE (P < 0.05). Multivariate analysis revealed that iAE were the only independent risk factors for postoperative complications (hazard ratio, 15.100; 95% confidence interval: 4.735-48.158, P < 0.001). Moreover, patients who experienced iAE had significantly lower satisfaction scores and poorer quality of life (P < 0.05).

CONCLUSIONS

ClassIntra may serve as an effective adjunctive tool for surgical quality control in laparoscopic radical hysterectomies.

Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

PURPOSE

Surgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice.

METHODS

A mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached.

RESULTS

There was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured.

CONCLUSIONS

Through an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed "core" steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The "optional" steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

Management of obstructive sleep apnea in children: a Canada-wide survey

BACKGROUND

Obstructive sleep apnea frequently persists in children following adenotonsillectomy, which is the first-line treatment recommended for obstructive sleep apnea with adenotonsillar hypertrophy. Drug-induced sleep endoscopy (DISE) is a diagnostic tool increasingly used to assess pediatric obstructive sleep apnea, but its use has not been standardized. The overarching goal of this study was to document the current practice of Canadian otolaryngologists managing this population.

METHODS

A nation-wide online cross-sectional survey of Canadian otolaryngologist members of the Canadian Society of Otolaryngology - Head and Neck Surgery and the Association d'otorhinolaryngologie et chirurgie cervico-faciale du Québec. The 58-question electronic survey was developed based on a validated survey redaction guide with the aim to assess management and treatment of pediatric obstructive sleep apnea, as well as indications and performance of DISE. Consensus on practice items was defined by a minimum of 75% similar answers.

RESULTS

One hundred and nine Canadian otolaryngologists completed the survey on management of pediatric obstructive sleep apnea, among which 12 of them completed the questions on DISE. Overall, there was a poor rate of agreement of 55% among the respondents for the 58 questions altogether. There was a consensus to assess pediatric obstructive sleep apnea clinically ± with videos (82.6%), to assess adenotonsillar hypertrophy clinically (93.6%) and with flexible scope in the office (80.7%), as well as for the airway sites examined endoscopically during DISE. However, there was no consensus regarding anesthetic protocol and scoring system. DISE was mostly performed in cases of persistent obstructive sleep apnea after adenotonsillectomy rather than before performing any surgical procedure. There was no difference in the management of obstructive sleep apnea between otolaryngologists who perform DISE and those who do not. The only difference between otolaryngologists who practice in community centers versus in tertiary care centers was the more frequently use of the Brodsky tonsil scale by the latter ones.

CONCLUSION

This Canadian-wide survey highlighted a lack of consensus in the management of pediatric obstructive sleep apnea and DISE. Certain aspects regarding DISE remain unclear, including establishment of its ideal timing in order to eventually avoid unnecessary tonsillectomies.

Constructivist Grounded Theory to Establish the Relationship Between Technical Error and Adverse Patient Outcome: Modeling Technical Error and Adverse Outcomes

BACKGROUND

Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes.

MATERIALS AND METHODS

We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons.

RESULTS

Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss.

DISCUSSION

Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Cognition errors in the treatment course of patients with anastomotic failure after colorectal resection

Background

Cognitive errors have a considerable effect on procedural outcome. They play a major role in situational judgement and decision making, especially during cognitively demanding tasks. As such they need to be considered an important factor in medical and surgical procedures. However, whereas cognitive diagnostic errors are well known, as of yet the occurrence of errors due to cognitive heuristics may have been downplayed, underestimated, or simply been ignored during the course of surgical treatment.

Methods

All colorectal resections with anastomosis in 2015 and 2016 (n = 230) were prospectively screened for anastomotic failure (n = 17/230). During structured Morbidity and Mortality Conferences (MMC) all anastomotic failures were analyzed for both tactical and technical decisions in the pre- and intraoperative setting with potential meaning for the postoperative course, based on the London Protocol. In order to demonstrate the significance of cognitive errors in surgical procedures a structured interview with the individual surgeon was conducted including the video and photo documentation of the individual surgical procedure. The interviews were coded by independent coders who were instructed to identify defined cognitive errors. Inter-coder agreement was calculated using Krippendorff’s alpha.

Results

In 12/17 patients with anastomotic failure after colorectal surgery tactical or technical decisions with potential negative influence on anastomotic healing or the postoperative course were assessed during MMC. In 8/12 procedures a structured interview could be conducted with the operating surgeon. In 7/8 procedures cognitive errors could be identified. In particular we found Anchoring (n = 1), Availability Bias (n = 1), Commission Bias (n = 1), Overconfidence Bias (n = 1), Omission Bias (n = 2) and Sunk Costs (n = 1).

Conclusion

Cognitive errors seem to play an important role during surgical therapy of patients with anastomotic failure after colorectal resection. Consequently, we suggest cognitive errors should attract more interest in research as well as attention in clinical practice.

Underreporting of Veress Needle Injuries: Comparing Direct Observation and Chart Review Methods

BACKGROUND

Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events.

MATERIALS AND METHODS

Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries.

RESULTS

Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts.

CONCLUSIONS

Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.

An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy

BACKGROUND

We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty.

METHODS

Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0-6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level.

RESULTS

Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. 'Diffuse scarring in the Calot's triangle area' in the 'Factors related to inflammation of the gallbladder' category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score.

CONCLUSIONS

A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

The Generic Error Rating Tool: A Novel Approach to Assessment of Performance and Surgical Education in Gynecologic Laparoscopy

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.

Characterising 'near miss' events in complex laparoscopic surgery through video analysis

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.

Identification of essential steps in laser procedure for twin-twin transfusion syndrome using the Delphi methodology: SILICONE study

OBJECTIVE

To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists.

METHODS

A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated  ≥ 4 by 80% of the experts were included in the evaluation instrument.

RESULTS

After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important.

CONCLUSIONS

A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.

Contemporary management of paraesophaegeal hernias: establishing a European expert consensus

BACKGROUND

The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology.

METHODS

A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach's α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed "undecided/controversial".

RESULTS

Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most "undecided/controversial" items were follow-up, postoperative care and surgical technique.

CONCLUSIONS

This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.

Identification of technique variations among microvascular surgeons and cases using hierarchical task analysis

A hierarchical taxonomy was developed for identifying differences among microvascular surgeons and cases and for investigating the impact of those differences on case outcome. Hierarchical task analysis was performed on eight microvascular anastomosis cases. The analysis was simplified by redefining subtasks and elements to only describe actions and adding attributes to describe the work object, method, tool, material, conditions and ergonomics factors. The resulting taxonomy was applied to 64 cases. Differences were found among cases for the frequency and duration of subtask, elements, attributes and element sequences. Observed variations were used to formulate hypotheses about the relationship between different methods and outcomes that can be tested in future studies. The taxonomy provides a framework for comparing alternative methods, determining the best methods for given conditions and for surgical training and retraining.

PRACTITIONER SUMMARY

A hierarchical taxonomy, created from a hierarchical task analysis and work attributes, was applied to describe technique variations among microsurgery cases. Variations in time, frequency and sequence were used to form hypotheses on best methods for standardising procedures.