What errors make a laparoscopic cancer surgery unsafe? An ad hoc analysis of competency assessment in the National Training Programme for laparoscopic colorectal surgery in England

Incentive policy for the comprehensive development of young medical talents: an evolutionary game study

Introduction

Currently in China, there is a lack of well-defined and viable incentive mechanisms at the governmental and hospital levels to support the development of young medical talents, thereby hindering their growth Existing studies primarily investigate the current state and trajectory of incentives, yet they inadequately address the distinctive characteristics of various stakeholders involved in medical talent incentive processes, particularly the lack of research on incentive mechanisms with Chinese attributes.

Methods

This study adopts evolutionary game theory to investigate the dynamics of replication and the strategies for achieving evolutionary stability in the comprehensive development of young medical talents, considering both scenarios with and without supportive policies.

Results

In the absence of any supportive policy measures, the evolutionarily stable strategy (ESS) point is O(0,0), the unstable equilibrium point is C(1,1), and the saddle points are A(0,1), B(1,0). The initial state of the system is at the unstable equilibrium point C(1,1), which means that the young medical talents and medical institutions adopt a combination of strategies (actively seeking comprehensive development and taking incentive measures). Under the scenario with supportive policies, the ESS point is C(1,1), the unstable equilibrium point is O(0,0), and the saddle points are A(0,1), B(1,0). The initial state of the system is at the unstable equilibrium point O(0,0), which means that young medical talents and medical institutions adopt (N,N) strategy combinations (inactively seeking comprehensive development, implementing no incentive measure).

Discussion

(1) Government incentives play a crucial role in motivating young medical talents to seek comprehensive development. (2) The level of government incentive support for young medical talents should exceed the cost increment of individual efforts. Additionally, the policy support provided by the government to medical institutions should surpass the incentive support offered by these institutions to young medical talents. This will enhance the motivation and encouragement efforts of medical institutions in actively promoting comprehensive development among young medical talents. (3) With the backing of certain government incentive policies, medical institutions implementing incentive measures and young medical talents actively seeking comprehensive development will establish a virtuous cycle of mutual promotion.

Change point analysis validation of the learning curve in laparoscopic colorectal surgery: Experience from a non-structured training setting

BACKGROUND

The introduction of minimal invasive principles in colorectal surgery was a major breakthrough, resulting in multiple clinical benefits, at the cost, though, of a notably steep learning process. The development of structured nation-wide training programs led to the easier completion of the learning curve; however, these programs are not yet universally available, thus prohibiting the wider adoption of laparoscopic colorectal surgery.

AIM

To display our experience in the learning curve status of laparoscopic colorectal surgery under a non-structured training setting.

METHODS

We analyzed all laparoscopic colorectal procedures performed in the 2012-2019 period under a non-structured training setting. Cumulative sum analysis and change-point analysis (CPA) were introduced.

RESULTS

Overall, 214 patients were included. In terms of operative time, CPA identified the 110^th case as the first turning point. A plateau was reached after the 145^th case. Subgroup analysis estimated the 58^th for colon and 52^nd case for rectum operations as the respective turning points. A learning curve pattern was confirmed for pathology outcomes, but not in the conversion to open surgery and morbidity endpoints.

CONCLUSION

The learning curves in our setting validate the comparability of the results, despite the absence of National or Surgical Society driven training programs.

The Balance Between Surgical Resident Education and Patient Safety in Laparoscopic Colorectal Surgery: Surgical Resident's Performance has No Negative Impact

OBJECTIVE

This study aimed to evaluate the feasibility and effectiveness of a comprehensive theoretical and hands-on training program in performing laparoscopic colonic resections under supervision of an expert surgeon.

MATERIALS AND METHODS

Laparoscopic right colectomy was performed in 78 patients (10 with benign disease, 68 with carcinoma). Demographic, intraoperative, pathologic examination, and short-term outcome data were retrospectively compared between 25 patients operated by surgical residents (R group) and 53 patients operated by senior surgeons (S group). The residents who performed surgeries in the R group had between 1 and 6 years after graduation; no experience with open or laparoscopic colorectal surgery was necessary. The residents completed a training program under supervision of a single expert laparoscopic colorectal surgeon, which included 6 steps, from basic skills to certification.

RESULTS

There were no differences in patient age, sex, and body mass index between the R and S groups. Significantly more patients in the R group had early cancer and benign lesions (P<0.05). Thirteen of the 16 residents (81.2 %) had not had prior experience with colonic resection. The time of suturing and knot tying in the dry box did not differ between residents and senior surgeons (68 and 69 s, respectively). All the residents performed laparoscopic right colectomy without intraoperative complications. There were no significant differences in operating time (R group: 173±34 min, S group: 172±52 min), mean estimated blood loss (50±111 vs. 49±100 mL), number of lymph nodes dissected (20.8±12.8 vs. 17.1±9.0), and mean postoperative hospital stay (9.1±3.3 vs. 10.7±4.1 d). On the basis of the year of their residency period, all 3 residents at 6 years after graduation had far greater experience than the other residents and therefore performed the surgery with minor verbal support from the expert. However, residents with 1 or 2 years after graduation had to receive guidance provision by the expert during surgery.

CONCLUSIONS

When supervised and led by an expert laparoscopic surgeon, surgical residents are capable of performing laparoscopic surgery without negative effects on outcomes.

Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis based on factors predictive of postoperative pancreatic fistula

BACKGROUND

Improvement in morbidity of pancreatoduodenectomy (PD) largely depends on the reduction in the incidence of clinically relevant (CR) postoperative pancreatic fistula (POPF).

METHODS

After internal validation of the clinical risk score (CRS) of POPF, and identification of other predictive factors for POPF, robotic (RPD), and open (OPD) PDs were stratified into risk categories and matched by propensity scores. The primary endpoint of this study was incidence of CR-POPF. Secondary endpoints were 90-day morbidity and mortality, and sample size calculation for randomized controlled trials (RCT).

RESULTS

No patient undergoing RPD was classified at negligible risk for POPF, and no CR-POPF occurred in 7 RPD at low risk. The matching process identified 48 and 11 pairs at intermediate and high risk for POPF, respectively. In the intermediate-risk group, RPD was associated with higher rates of CR-POPF (31.3% vs 12.5%) (p = 0.0026), with equivalent incidence of grade C POPF. In the high-risk group, CR-POPF occurred frequently, but in similar percentages, after either procedures. Starting from an unadjusted point estimate of the effect size of 1.71 (0.91-3.21), the pair-matched odds ratio for CR-POPF after RPD was 2.80 (1.01-7.78) for the intermediate-risk group, and 0.20 (0.01-4.17) for the high-risk group. Overall morbidity and mortality were equivalent in matched study groups. Sample size calculation for a non-inferiority RCT demonstrated that a total of 31,669 PDs would be required to randomize 682 patients at intermediate risk and 1852 patients at high risk.

CONCLUSIONS

In patients at intermediate risk, RPD is associated with higher rates of CR-POPF. Incidence of grade C POPF is similar in RPD and OPD, making overall morbidity and mortality also equivalent. A RCT, with risk stratification for POPF, would require an enormous number of patients. Implementation of an international registry could be the next step in the assessment of RPD.

Errors and complications in laparoscopic surgery

Background. In laparoscopic surgery errors are unavoidable and require proper acknowledgment to reduce the risk of intraoperative and accurately assess the appropriate therapeutic approach. Fortunately, their frequency is low and cannot overshadow the benefits of laparoscopic surgery. Materials and Methods. We made an epidemiological investigation in General Surgery Department of Emergency Clinical Hospital "St. John" Bucharest, analyzing 20 years of experience in laparoscopic surgery, during 1994-2014. We wanted to identify evolution trends in complications of laparoscopic surgery, analyzing the dynamic of errors occurred in all patients with laparoscopic procedures. Results. We recorded 26847 laparoscopic interventions with a total of 427 intra-or postoperative complications that required 160 conversions and 267 reinterventions to resolve inconsistencies. The average frequency of occurrence of complications was 15.9‰ (15.9 of 1,000 cases). In the period under review it was a good momentum of laparoscopic procedures in our department. Number of minimally invasive interventions increased almost 10 times, from 266 cases operated laparoscopically in 1995 to 2638 cases in 2008. Annual growth of the number of laparoscopic procedures has surpassed the number of complications. Conclusions. Laborious work of laparoscopic surgery and a specialized centre with well-trained team of surgeons provide premises for a good performance even in the assimilation of new and difficult procedures.

[Risk awareness and training for prevention of complications in minimally invasive surgery]

BACKGROUND

Minimally invasive surgery (MIC) requires surgeons to have a different set of skills and capabilities from that of open surgery. The indirect camera view, lack of a three-dimensional view, restricted haptic feedback with lack of tissue feeling and difficult instrument coordination with fulcrum and pivoting effects result in an additional learning curve compared to open surgery. The prolonged learning curve leads to a higher risk of complications and special awareness of these risks is therefore mandatory. Training of special laparoscopic skills outside the operating room is needed to optimize patient outcome and to minimize the ocurrence of complications related to the learning curve.

RESULTS AND DISCUSSION

Training modalities for laparoscopic surgery include simple box trainers, computer simulation with virtual reality, the use of artificial and cadaver organs, as well as live animal models and cadaver training. These training modalities have been proven in studies to have a beneficial effect on the learning curve for acquisition of laparoscopic skills and for improving operative performance as well as avoidance of complications. Laparoscopic training is currently gaining a more and more important role for official education and accreditation purposes. In some countries the participation in laparoscopic training courses has become mandatory prior to participation in laparoscopic operations. Future research will include the optimization of multimodal training curricula, the development of individualized training approaches that allow both trainee and patient-specific preparation, as well as the use of novel devices to facilitate the collection and transfer of expertise between the generations and schools of surgeons.

Learning curves and surgical outcomes for proctored adoption of laparoscopic ventral mesh rectopexy: cumulative sum curve analysis

BACKGROUND

Laparoscopic ventral mesh rectopexy (VMR) is an effective and well-recognised treatment for symptoms of obstructive defecation in the context of rectal prolapse and recto-rectal intussusception. However, due to the technical complexity of VMR, a significant learning curve has been previously described. This paper examines the effect of proctored adoption of VMR on learning curves, operative times, and outcomes.

METHODS

A retrospective database analysis of two district general hospitals was conducted, with inclusion of all cases performed by two surgeons since first adoption of the procedure in 2007-2015. Operative time, length of stay, and in-hospital complications were evaluated, with learning curves assessed using cumulative sum curves.

RESULTS

Three hundred and eleven patients underwent VMR during the study period and were included for analysis. Patients were near-equally distributed between surgeons (surgeon A: n = 151, surgeon B, n = 160) with no significant differences between gender, age, or ASA grade. In-hospital morbidity was 3.2 %, with 0 % mortality. Cumulative sum curve analysis suggested a change point of between 25 and 30 cases based on operative times and length of stay and was similar between both surgeons. No significant change point was seen for morbidity or mortality.

CONCLUSION

VMR is an effective and safe treatment for rectal prolapse. Surgeons in this study were proctored during the adoption process by another surgeon experienced in VMR; this may contribute to increased safety and abbreviated learning curve. In the context of proctored adoption, this study estimates a learning curve of 25-30 cases, without detrimental impact on patient outcomes.

The effect of mentoring on clinical perioperative competence in operating room nursing students

AIMS AND OBJECTIVES

The aim of this study was to investigate the effects of mentoring on the clinical perioperative competence of nursing operating room students in Iran.

BACKGROUND

Mentoring is an essential part of clinical education, which has been studied in different populations of students. However, there is a need to assess its effectiveness in operating room students' competence.

DESIGN

A randomised controlled trial was performed.

METHODS

Sixty nursing operating room students were randomly assigned to experimental and control groups. Both the control and experimental groups had routine training in the form of faculty supervision. The experimental group had an additional mentoring program. Using the Persian Perceived Perioperative Competence Scale-Revised, clinical competence was compared between the two groups, before and after the intervention. Using SPSS 19, descriptive and inferential statistics, including chi-square and t-tests, were conducted.

RESULTS

In the experimental group, the difference between the mean scores of clinical competence before (19·43 ± 2·80) and after (27·86 ± 1·87) the intervention was significant (p ≤ 0·001). After intervention, the difference between the mean scores of the control (3·9 ± 0·15) and experimental (8·61 ± 0·68) groups was significant (p ≤ 0·003).

CONCLUSION

Findings affirmed the positive effect of mentorship programmes on clinical competence in nursing operating room students.

RELEVANCE TO CLINICAL PRACTICE

Mentoring is an effective method for preparing nursing students in practice. Health care systems may improve as a result of staff-student relationships that ultimately increase the quality care for patients.