Standardizing laparoscopic procedure time and determining the effect of patient age/gender and presence or absence of surgical residents during operation. A prospective multicenter trial

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult LC in Surgical Missions

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes.

MATERIALS AND METHODS

A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension.

RESULTS

68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC.

CONCLUSION

Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

A Step-Wise Approach to Total Laparoscopic Gastrectomy with Jejunal Pouch Reconstruction: How and Why We Do It

Laparoscopic gastrectomy (LG) is a safe alternative compared to open gastrectomy for cancer. To increase the uptake of minimally invasive approaches and facilitate their analysis and improvement a stepwise approach is warranted. This study describes our technique and experiences total laparoscopic gastrectomy (TLG) with jejunal pouch reconstruction for gastric cancer. Technical modifications throughout the years were described. In patients with anastomotic leakage, the CT-scan and reoperation report were reviewed to identify the location and cause of the leak. A total of 47 patients who underwent laparoscopic total gastrectomy with extracorporeal jejunal pouch reconstruction and stapled circular esophagojejunostomy from May 2007 to August 2015 were prospectively analyzed. A stepwise approach of 10 steps was designed based on video and case analysis. Median operation time was 301 (148-454) minutes and median blood loss was 300 (30-900) milliliters. Anastomotic leakage occurred in six (12.8 %) patients; additionally, one (2.12 %) jejunal-pouch staple line leak was identified. An important modification in our technique was a purse-string suture around the anvil of the circular stapler to prevent esophageal mucosa to slip away. After this modification, the leakage rate was reduced to 7 % in the last 15 procedures. In conclusion, TLG with jejunal pouch reconstruction is a feasible procedure in a selected group of patients. Our stepwise approach and technique may help surgeons to introduce jejunal pouch reconstruction during laparoscopic gastrectomy in their center.

The Effect of Afternoon Operative Sessions of Laparoscopic Cholecystectomy Performed by Senior Surgeons on the General Surgery Residency Program: A Comparative Study

OBJECTIVE

Laparoscopic cholecystectomy (LC) has been the gold standard for surgical treatment of gallbladder disease since 1980. This laparoscopic surgical procedure is one of the first to be performed by general surgery residents. There is a learning curve required to excel at performing LC. During this period, the operation needs to be performed under the supervision of a senior surgeon. The purpose of this study was to compare LC performed by residents with that performed by senior surgeons using the following parameters: operative time, conversion rate, complication rate, and mean length of hospital stay.

METHODS

This retrospective study included 1219 patients who underwent elective LC in our institute-788 operated on by a senior surgeon and 431 by a resident.

RESULTS

The mean operative time was 39 ± 19 minutes. There was a significant difference between the groups, as the mean operative time for the resident group was 49.9 ± 13 compared with 33.7 ± 6 for the senior surgeon group. The overall conversion rate was 2.1%, the complication rate was 2.2%, and the mean length of hospital stay was 1.5 days. There were no statistically significant differences between the groups for these parameters.

CONCLUSIONS

The only significant difference between the groups was a longer operative time, as the conversion rate, complication rate, and mean length of stay were the same. Therefore, it is safe for LC to be performed by residents supervised by a senior surgeon.

Detecting performance variance in complex surgical procedures: analysis of a step-wise technique for laparoscopic right hepatectomy

BACKGROUND

Laparoscopic right hepatectomy (LRH) is a technically challenging operation. Our aim is to evaluate a standardized technique of LRH and determine variances in performance.

METHODS

The procedure was deconstructed into 7 major step-wise components. All LRH followed the same surgical sequence, and used the same devices and operating room set-up. Thirty randomly selected video recordings of the procedure underwent intraoperative time analysis. The variances measured by standard deviation of each step were calculated (mean in minutes ± standard deviation).

RESULTS

Mean total operative time was 114 ± 25 min. The steps with the least variance were inferior vena cava dissection (8 ± 3) and right hepatic vein ligation (9 ± 5). The longest and also the step with the greatest variance was parenchymal transection (35 ± 12).

CONCLUSIONS

LRH can be performed consistently using a standardized step-wise technique. Parenchymal transection had most variation, and this could be explained by intrinsic liver factors. Surgical performance improvement should begin with deconstructing the operation into definable steps to identify areas for change.

Impact of risk factors for prolonged operative time in laparoscopic cholecystectomy

OBJECTIVE

Laparoscopic cholecystectomy (LC) remains one of the most frequent surgical therapies for symptomatic gallstone disorders. Prolonged operative time is frequently associated with increased complication rates. The aim of this study was to identify the risk factors for prolonged operative times to minimize perioperative morbidity and optimize clinical management.

METHODS

A total of 677 consecutive patients underwent LC. The exclusion criteria were conversion to an open procedure, intraoperative cholangiography, and liver cirrhosis (n=81). Data were analyzed retrospectively with respect to age, sex, BMI, ASA score, previous abdominal surgery, preoperative endoscopic retrograde cholangiopancreatography, acute cholecystitis, and surgeon's experience. Univariate and multivariate analyses were performed.

RESULTS

A total of 596 patients, mean (± SD) age of 52.2 ± 16.7 years, were analyzed. In all, 29% of the patients were obese (BMI ≥ 30 kg/m); 11% had ASA III. Five percent of patients had undergone previous upper abdominal surgery. Overall, 105/596 patients had an acute cholecystitis. Residents of general surgery performed 58% of all operations. The median operative time was 80 min (range, 15-281 min). No statistical significance was found between intraoperative and postoperative complications by surgeon's experience. Statistically, independent preoperative predictors for prolonged operative time as identified through multivariate analysis were acute cholecystitis, obesity, previous upper abdominal surgery, male sex, and low degree of surgical expertise.

CONCLUSION

The risk for prolonged operative times in LC can be assessed on the basis of patients' characteristics. Assessment of these factors not only helps to optimize the individual outcome for each patient but also improves the decision process toward operative training for junior surgeons.

Lost opportunity cost of surgical training in the Australian private sector

BACKGROUND

To meet Australia's future demands, surgical training in the private sector will be required. The aim of this study was to estimate the time and lost opportunity cost of training in the private sector.

METHODS

A literature search identified studies that compared the operation time required by a supervised trainee with a consultant. This time was costed using a business model.

RESULTS

In 22 studies (34 operations), the median operation duration of a supervised trainee was 34% longer than the consultant. To complete a private training list in the same time as a consultant list, one major case would have to be dropped. A consultant's average lost opportunity cost was $1186 per list ($106,698 per year). Training in rooms and administration requirements increased this to $155,618 per year. To train 400 trainees in the private sector to college standards would require 54,000 training lists per year. The consultants' national lost opportunity cost would be $137 million per year. The average lost hospital case payment was $5894 per list, or $330 million per year nationally. The total lost opportunity cost of surgical training in the private sector would be about $467 million per year. When trainee salaries, other specialties and indirect expenses are included, the total cost will be substantially greater.

CONCLUSION

It is unlikely that surgeons or hospitals will be prepared to absorb these costs. There needs to be a public debate about the funding implications of surgical training in the private sector.

The Impact of Anaesthetic Trainees on Elective Caesarean Section Procedural Times: A Prospective Observational Study

Operating room efficiency is an important concern in hospitals today both in the public and private sectors. Currently, a paucity of literature exists to evaluate the impact of anaesthetic training on operating room efficiency in the Australian health system. At Monash Medical Centre, Clayton, private consultant operating sessions and public teaching operating sessions use the same operating theatres, nursing and technical staff. Consultant anaesthetists and obstetricians perform all tasks during private sessions, whereas anaesthetic and obstetric trainees perform many tasks during public sessions. In this prospective observational study, total case time, anaesthesia controlled time and the surgical time were measured for elective caesarean section under spinal anaesthesia in 59 patients (private consultantn=29, public teaching n=30). Increases in total case time (24 minutes, P <0.001), anaesthesia controlled time (5.2 minutes, P <0.015) and surgical time (19.25 minutes, P <0.001) were observed in the public teaching group compared with the private consultant group. The participation of anesthetic trainees in caesarean sections results in a modest increase in anaesthetic controlled time of approximately five minutes per case or 16 minutes in an operative session with three cases scheduled. Elimination of anaesthetic ‘training’ time does not allow scheduling of an extra elective caesarean section. Reduced operating theatre throughput is unlikely to be a consequence of training specialist anaesthetists in this clinical setting.

Opportunity costs of gastrointestinal endoscopic training in Canada

BACKGROUND

No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards.

OBJECTIVE

To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training.

METHODS

Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data.

RESULTS

Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration.

CONCLUSIONS

Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.

Operating room management: why, how and by whom?

Operating room (OR) is a cost-intensive environment, and it should be managed efficiently. When improving efficiency, shortening case duration by parallel processing, training of the resident surgeons, the choice of anesthetic methods, effective scheduling, and monitoring of the overall OR performance are important. When redesigning the OR processes, changes should be given a clear target and the achieved results monitored and reported to everyone involved. Advanced, reliable, and easy to use information technology solutions for OR management are under development. Pre-operative clinic and functionally designed facilities support efficiency. OR personnel must be kept motivated by clear management and leadership, supported by superiors.

Rapid Communication: Small Changes in Operative Time Can Yield Discrete Increases in Operating Room Throughput

BACKGROUND AND PURPOSE

Operating room throughput is influenced by the efficiency of the perioperative process (for nonoperative time) and by the surgeon (for operative time). Operative time is thought not to be easily amenable to deliberate reductions. We tested the hypothesis that gradual improvements in operative time had allowed one surgeon to perform additional cases during scheduled hours.

MATERIALS AND METHODS

The surgeon had been working in both a high-throughput and a conventional operating room for more than 1 year prior to the study. During the studied interval, we applied statistical process control analysis to time data for the surgeon performing full days of complex laparoscopic operations. Separate analyses were conducted for the conventional and high-throughput operating rooms. The average operative time for each day and the number of cases per day were plotted against sequential days for each environment.

RESULTS

Midway through the studied interval, there was a discrete 17-minute drop in operative time in both the high-throughput and the conventional environment. Throughput increased from two cases per day to three per day in the high-throughput environment. The average end time for the three-case days was 17:15 (range 16:04-18:32). Longer average operative and nonoperative times in the conventional rooms precluded performing three complex cases during regular work hours.

CONCLUSION

There was a sudden, rather than a gradual, reduction of operative time leading to extra cases being performed. This coincided with (1) the surgeon being assigned a new fellow and (2) administrative commitment to finish three cases per day. Our original hypothesis was negated, but other controllable causes for changes in surgical throughput were identified.

Three-port versus four-port laparoscopic cholecystectomy in acute and chronic cholecystitis

BACKGROUND

Several modifications have been introduced to laparoscopic cholecystectomy (LC). The three-port technique has been practiced on a limited scale. Our aim was to compare the three-port and four-port LC in acute (AC) and chronic cholecystitis (CC).

METHODS

The medical records of 495 patients who underwent LC between September 1999 and September 2003 were reviewed. Variables such as complications, operating time, conversion to open procedure, hospital stay, and analgesia requirements were compared.

RESULTS

Two hundred and eighty-three patients underwent three-port LC and 212 patients underwent four-port LC. In total, 163 (32.9%) patients were diagnosed with AC and 332 (67.1%) with CC by histology. There was no statistical difference between the three and four-port groups in terms of complications, conversion to open procedure (p = 0.6), and operating time (p = 0.4). Patients who underwent three-port LC required less opiate analgesia (pethidine) than those who underwent four-port LC (p = 0.0001). The hospital stay was found to be related to the amount of opiates consumed (p = 0.0001) and was significantly shorter in the three-port LC group (p = 0.005).

CONCLUSION

Three-port LC is a safe procedure for AC and CC in expert hands. The procedure offers considerable advantages over the traditional four-port technique in the reduction of analgesia requirements and length of hospital stay.

Laparoscopic Nissen fundoplication in a patient with situs inversus totalis: an ergonomic consideration

We report a laparoscopic Nissen fundoplication for gastroesophageal reflux disease in a patient with situs inversus totalis. The 65-year-old man was previously diagnosed with situs inversus totalis and presented with chronic gastroesophageal reflux disease inadequately controlled by medications. The laparoscopic procedure was performed with 5 ports placed in a mirror-image configuration and with the patient in the lithotomy position. Few technical difficulties were encountered during the operation. The position of the primary surgeon, working between the lower limbs of the patient, was considered critical to the success of this case. In situs inversus totalis, this position provides the least visual disorientation from the reversed abdominal organs. We recommend this position for all upper abdominal laparoscopic procedures in patients with situs inversus totalis, including laparoscopic cholecystectomy.

Experimental assessment of a new mechanical endoscopic solosurgery system: Endofreeze

BACKGROUND

The assistance received by the surgeon from support personnel during operative laparoscopy is extremely important. This includes retraction of instruments and endoscope positioning. However, human assistance is costly and often does not provide satisfaction for the surgeon. The aim of this study was to develop a mechanical arm capable of allowing easy handling and holding of laparoscopic instruments under the surgeon's control.

METHODS

We designed a system, named Endofreeze, based on a particular kinematical construction that maintains an invariant point of constraint motion just above the trocar puncture site through the abdominal wall. The goal was to develop this way a highly intuitive mechanical holding system for laparoscopic instruments, with sufficient precision of action, activated by a single hand movement. We tested a couple of prototypes with different holding arms while performing cholecystectomy in phantom models with swine inserts and compared the results obtained in similar conditions using different holding and positioning systems.

RESULTS

The system allows transparent and intuitive operation, and its setup is easy and quick. It may be adapted either as an instrument retractor or as an optic positioning device. Compared to different systems available or prototypes previously tested, such as AESOP 2000, ENDOASSIST, FIPS Endoarm, TISKA Endoarm, and the Martin Arm, in similar conditions, it was more intuitive, allowing shorter time for completion of surgery.

CONCLUSION

Endofreeze is a new intuitive mechanical positioning system for endoscopic solo surgery. In phantom models, it demonstrated a shorter time requirement for completion of surgery when compared to other systems available. In our opinion, it represents a valid compromise between human and robotic control for conventional laparoscopic instruments.

Analysis of procedure time in robot-assisted surgery: comparative study in laparoscopic cholecystectomy

INTRODUCTION

Robotic surgery systems have been introduced to deal with the basic disadvantages of laparoscopic surgery. However, working with these systems may lead to time loss due to additional robot-specific tasks, such as set-up of equipment and sterile draping of the system. To evaluate loss of time in robot-assisted surgery, we compared 10 robot-assisted cholecystectomies to 10 standard laparoscopic cholecystectomies.

MATERIALS AND METHODS

The robot-assisted procedures were performed with the da Vinci telemanipulation system. The total time in the operating room (OR) was scored and divided into preoperative, operative, and postoperative phases. These phases were further divided into smaller time-frames to precisely define moments of time loss.

RESULTS

The most significant difference between the two groups was found in the preoperative phase. Robot-related tasks led to time loss in all time-frames of this phase. In the operative phase, the trocar entry time-frame was longer in robot-assisted cases than in standard procedures. Additionally, postoperative OR clearing was longer in the robot-assisted cases. Total operating time did not differ significantly between the two procedures.

CONCLUSION

Robot-assisted surgery leads to time loss during preparation of routine laparoscopic procedures.

Optimization of operating room allocation using linear programming techniques

BACKGROUND

New and innovative approaches must be used to rationally allocate scarce resources such as operating room time while simultaneously optimizing the associated financial return. In this article we use the technique of linear programming to optimize allocation of OR time among a group of surgeons based on professional fee generation.

STUDY DESIGN

For the period of December 1, 2000, to July 31, 2002, the following individualized data were obtained for the Division of General Surgery at Duke University Medical Center: allocated OR time (hours), case mix as determined by CPT codes, total OR time used, and normalized professional charges and receipts. Inpatient, outpatient, and emergency cases were included. The Solver linear programming routine in Microsoft Excel (Microsoft Corp.) was used to determine the optimal mix of surgical OR time allocation to maximize professional receipts.

RESULTS

Our model of optimized OR allocation would maximize weekly professional revenues at 237,523 US dollars, a potential increase of 15% over the historical value of 207,700 US dollars or an annualized increase of approximately 1.5 million US dollars.

CONCLUSIONS

Our results suggest that mathematical modeling techniques used in operations research, management science, or decision science may rationally optimize OR allocation to maximize revenue or to minimize costs. These techniques may optimize allocation of scarce resources in the context of the goals specific to individual academic departments of surgery.

Bile duct injury during laparoscopic cholecystectomy: results of a national survey

OBJECTIVE

To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency.

SUMMARY BACKGROUND DATA

Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern.

METHODS

An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

RESULTS

Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair.

CONCLUSIONS

Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Automated high-frequency posture sampling for ergonomic assessment of laparoscopic surgery

BACKGROUND

Despite widespread acknowledgement that strain injuries do occur to surgeons, ergonomic assessments in minimally invasive surgery are comparatively rare. Current assessment techniques rely on labor-intensive manual recording techniques, so there is a need for an automated system.

METHODS

We used an optoelectronic measurement system to make postural measurements at frequencies of ~5 Hz and then converted these measurements to ergonomic stress scores using a modified Rapid Upper Limb Assessment (RULA) method.

RESULTS

We successfully recorded postures at least once per second during 96% of the time the surgeon was performing tissue manipulation tasks. We found that the ergonomic stress scores were comparatively high throughout the procedure, particularly for the wrist.

CONCLUSION

An automated high-frequency postural measurement system is feasible for making ergonomic assessments in an intraoperative setting. Such a system will also be a critical component in validating surgical simulations for use in training and credentialing surgeons and in designing and evaluating equipment.

Telerobotic laparoscopic cholecystectomy: initial clinical experience with 25 patients

OBJECTIVE

To determine the safety and feasibility of performing telerobotic laparoscopic cholecystectomies. This will serve as a preliminary step toward the integration of computer-rendered three-dimensional preoperative imaging studies of anatomy and pathology onto the patient's own anatomy during surgery.

SUMMARY BACKGROUND DATA

Computer-assisted surgery (CAS) increases the surgeon's dexterity and precision during minimally invasive surgery, especially when using microinstruments. Clinical trials have shown the improved microsurgical precision afforded by CAS in the minimally invasive setting in cardiac and gynecologic surgery. Future applications would allow integration of preoperative data and augmented-reality simulation onto the actual procedure.

METHODS

Beginning in September 1999, CAS was used to perform cholecystectomies on 25 patients at a single medical center in this nonrandomized, prospective study. The operations were performed by one of two surgeons who had previous laboratory experience using the computer interface. The entire dissection was performed by the surgeon, who remained at a distance from the patient but in the same operating room. The operation was evaluated according to time of dissection, time of assembly/disassembly of robot, complications, immediate postoperative course, and short-term follow-up.

RESULTS

Twenty of the 25 patients had symptomatic cholelithiasis, 1 had a gallbladder polyp, and 4 had acute cholecystitis. Twenty-four of the 25 laparoscopic cholecystectomies were successfully completed by CAS. There was one conversion to conventional laparoscopic cholecystectomy. Set-up and takedown of the robotic arms took a median of 18 minutes. The median operative time for dissection and the overall operative time were 25 and 108 minutes, respectively. There were no intraoperative complications. There was one postoperative complication of a suspected pulmonary embolus, which was treated with anticoagulation. All patients were tolerating diet at discharge.

CONCLUSIONS

Laparoscopic cholecystectomy performed by CAS is safe and feasible, with operative times and patient recovery similar to those of conventional laparoscopy. At present, CAS cholecystectomy offers no obvious advantages to patients, but the potential advantages of CAS lie in its ability to convert the surgical act into digitized data. This digitized format can then interface with other forms of digitized data, such as pre- or intraoperative imaging studies, or be transmitted over a distance. This has the potential to revolutionize the way surgery is performed.

Analysis of the quality and efficiency in learning laparoscopic skills

OBJECTIVES

This study demonstrates the application of time-action analysis to the evaluation of task performance of diagnostic laparoscopy with laparoscopic ultrasonography.

METHODS

The first 25 diagnostic laparoscopies with laparoscopic ultrasonography performed by a surgical resident were analyzed and compared with the outcomes of these procedures performed by an experienced surgeon. The time, actions, and correctness of task performance were evaluated. Furthermore, outcome correctness and postoperative complications were assessed.

RESULTS

No postoperative complications occurred. The resident made one wrong diagnosis, for which the cause was detected by peroperative analysis. Additionally, 1% of the subtasks were performed only partially, 4% not at all, and 2% using the wrong technique. The efficiency for most diagnostic tasks remained significantly lower than that of the experienced surgeon (p < 0.001).

CONCLUSIONS

Time-action analysis can be used to provide detailed insight into the quality and efficiency of learning surgical skills. It enables objective measurement of correctness in task performance as well as time and action efficiency.

A critical analysis of intraoperative time utilization in laparoscopic cholecystectomy

BACKGROUND

Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operation room; however, heretofore there has been no critical analysis of the time required to perform the various steps of the operation. An understanding of how operative time is used is the first step toward improving the efficiency of the procedure and decreasing costs while maintaining an acceptable standard of care.

METHODS

Of 194 patients undergoing LC at a university hospital between 1994 and 1997, operational videotapes of 48 randomly chosen patients were reviewed. Three groups of patients were identified: those undergoing LC for chronic cholecystitis (n = 27), those undergoing LC for acute cholecystitis (n = 11), and those with common bile duct stones (CBDS), (n = 10) undergoing LC with transcystic common bile duct exploration. The procedure was divided into the following seven steps; trocar entry, laparoscopic ultrasound, dissection of the triangle of Calot, cholangiogram, dissection of the gallbladder, extraction of the gallbladder, and irrigation-aspiration with removal of ports. Time spent for camera cleaning, bleeding control, and insertion of the cholangiocatheter into the cystic duct was also calculated. The groups were compared in terms of time spent for each step using the Kruskal-Wallis and Mann-Whitney U tests.

RESULTS

The mean +/- SD operating time was 66.5 +/- 20.5 min. The acute group had the longest operating time, followed by the CBDS and chronic groups. Dissection of the gallbladder, insertion of the cholangiocatheter, and irrigation-aspiration were longer steps in the acute group than in the other groups (p < 0.05). Dissection of the triangle of Calot took longer in acute cholecystitis than in chronic cholecystitis (p < 0.05). CBDS cases took longer (p < 0.05) than chronic cases because stone extraction added an average of 17.5 min to the time required for the cholangiogram in chronic cholecystitis. Laparoscopic ultrasound took longer in the CBDS group than in the other groups (p < 0.05). The mean +/- SD time spent for the cholangiogram and laparoscopic ultrasound in chronic cholecystitis was 7.5 +/- 4.3 and 4.8 +/- 1.9 min, respectively.

CONCLUSIONS

This time analysis study demonstrates that acute cholecystitis requires a longer operating time because most of the individual steps in the procedure take longer. In patients with choledocholithiasis, stone extraction was responsible for longer operating times. This study should serve as a basis for future studies focusing on time utilization in laparoscopic surgery.

Colecistectomia agulhascópica: aspectos técnicos e resultados iniciais

Os autores descrevem a técnica que utilizaram para a realização da colecistectomia agulhascópica no Núcleo de Hospital de Aeronáutica de Manaus, de setembro de 1997 a maio de 1999, e os resultados iniciais obtidos em 83 pacientes (11 do sexo masculino e 72 do feminino, com idades variando de 17 a 87 anos) portadores de doenças da vesícula biliar. Empregaram, além de um equipamento completo de videolaparoscopia, um equipamento acessório composto de um monitor de vídeo, uma microcâmera, com seu processador de imagens, e uma fonte de luz, tudo para o laparoscópio de 1,7 mm MiniSite®. A operação foi realizada principalmente sob monitoramento videolaparoscópico de 10 mm pelo portal umbilical e por meio de três portais de 2 mm (epigástrico, hipocôndrio direito e flanco direito). Utilizou-se o videolaparoscópio de 2 mm pelo portal epigástrico quando se procedeu às ligaduras císticas, ocasião em que o laparoscópio de 10 mm umbilical era substituído pelo aplicador de clipes de 10 mm. Da mesma forma, a vesícula foi retirada da cavidade abdominal pelo portal umbilical sob monitoramento videolaparoscópico de 1,7 mm epigástrico. A maioria dos casos operados (89,2%) não apresentava espessamento da parede vesicular. O tempo cirúrgico médio do procedimento foi de 92 ± 21 min e o de internação foi de 16 h. A principal intercorrência operatória foi a perfuração da vesícula biliar (41%), atribuída à curva de aprendizado no método por que passa a equipe. Vômitos foram a principal complicação pós-operatória (51,8%), não tendo havido infecção de ferida operatória. Oitenta e dois por cento dos casos puderam ser terminados pelo método agulhascópico puro, enquanto em 6% e 3,6%, respectivamente, houve necessidade de trocar um dos portais de 2 mm por um de 5 ou de 10 mm e de converter o procedimento para videolaparoscopia usual. Em 6% dos casos, por problemas de imagem com o microlaparoscópio, realizou-se o procedimento agulhascópico com a assistência de um portal suprapúbico de 10 mm. Dois casos (2,4%) tiveram que ser convertidos para laparotomia convencional, um por problemas operacionais com o equipamento e outro por dificuldades técnicas transoperatórias. Os autores concluem ser o procedimento agulhascópico factível, demandar uma nova curva de aprendizado por parte da equipe e ser demorado em virtude das características de seus instrumental e equipamento.

Peroperative time-motion analysis of diagnostic laparoscopy with laparoscopic ultrasonography

BACKGROUND

Advanced technology is being introduced rapidly into laparoscopic procedures, frequently without an accurate evaluation of its functioning. In this study, standardized time-motion analysis was applied to evaluate the peroperative surgical process and the technical equipment used in 18 cases of diagnostic laparoscopy with laparoscopic ultrasonography (DLLU).

METHODS

The image through the laparoscope, the ultrasonograph and an overview of the operating theatre were recorded simultaneously. The time for each phase, efficient actions (e.g. identifying lesions by inspection, making an ultrasonogram or taking a biopsy) and limiting factors (e.g. technical problems, time spent waiting) were determined, and a current standard was defined.

RESULTS

Of the actions performed, 52 per cent were qualified as efficient, 17 per cent were classified as time spent waiting for personnel, instruments were positioned in 13 per cent, and unnecessary instrument exchanges were involved in 10 per cent. The evaluation led to a significant reduction in delay times and resulted in design criteria for improved biopsy instruments. The current standard was calculated from the mean time and number of actions determined for each phase.

CONCLUSION

This time-motion study provided detailed insight into the peroperative process of DLLU, leading to improvements in the surgical process and instruments used. The defined current standard will enable evaluation of the learning curve and new technologies.