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

Laparoscopic versus open major liver resection for hepatocellular carcinoma: systematic review and meta-analysis of comparative cohort studies

Background

The application of laparoscopic liver resection (LLR) has expanded rapidly in recent decades. Although multiple authors have reported LLR shows improved safety and efficacy in treating hepatocellular carcinoma (HCC) compared with open liver resection (OLR), laparoscopic (LMLR) and open (OMLR) major liver resections for HCC treatment remain inadequately evaluated. This work aimed to test the hypothesis that LMLR is safer and more effective than OMLR for HCC.

Methods

Comparative cohort and registry studies on LMLR and OMLR, searched in PubMed, the Science Citation Index, EMBASE, and the Cochrane Library, and published before March 31, 2018, were collected systematically and meta-analyzed. Fixed- and random-effects models were employed for generating pooled estimates. Heterogeneity was assessed by the Q-statistic.

Results

Nine studies (1173 patients) were included. Although the pooled data showed operation time was markedly increased for LMLR in comparison with OMLR (weighted mean difference [WMD] 74.1, 95% CI 35.1 to 113.1, P = 0.0002), blood loss was reduced (WMD = − 107.4, 95% CI − 179.0 to − 35.7, P = 0.003), postoperative morbidity was lower (odds ratio [OR] 0.47, 95% CI 0.35 to 0.63, P <  0.0001), and hospital stay was shorter (WMD = − 3.27, 95% CI − 4.72 to − 1.81, P <  0.0001) in the LMLR group. Although 1-year disease-free survival (DFS) was increased in patients administered LMLR (OR = 1.55, 95% CI 1.04 to 2.31, P = 0.03), other 1-, 3-, and 5-year survival outcomes (overall survival [OS] and/or DFS) were comparable in both groups.

Conclusions

Compared with OMLR, LMLR has short-term clinical advantages, including reduced blood loss, lower postsurgical morbidity, and shorter hospital stay in HCC, despite its longer operative time. Long-term oncological outcomes were comparable in both groups.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

BACKGROUND

With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar.

METHODS

MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016.

RESULTS

Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002).

CONCLUSIONS

Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Low conversion rate during minimally invasive major hepatectomy: Ten-year experience at a high-volume center

BACKGROUND

Minimally invasive approaches for major hepatectomy have been marred by significant rates of conversion and associated morbidity. This study aimed to determine risk factors for conversion as well as postoperative morbidity in patients undergoing minimally invasive right-sided hepatectomy (MIRH).

METHODS

Data for patients undergoing MIRH between 2008 and 2017 at Emory University were reviewed. Risk factors for conversion were determined using multivariate regression analysis. Outcomes of conversion patients were compared with those who underwent successful MIRH or elective open surgery.

RESULTS

Unplanned conversion occurred in 7 (6.25%) of 112 patients undergoing MIRH. Primary reason for conversion was difficult dissection secondary to inflammation and severe adhesions. No preoperative clinical factor was identified that predicted conversions. Converted cases had higher EBL and pRBC transfusion compared to non-converted cases however morbidity was similar to those undergoing primary open surgery.

CONCLUSION

Difficult dissection and adhesions remained the only clinically applicable parameter leading to unplanned conversions. While these did offset benefits of a successful minimally invasive approach, it did not increase risk of postoperative complications compared with planned open surgery.

Operating room efficiency

The operating room is the financial hub of any hospital, and maximizing operating room efficiency has important implications for cost savings, patient satisfaction, and medical team morale. Over the past decade, manufacturing principles and processes such as Lean and Six Sigma have been applied to various aspects of healthcare including the operating room. Although time consuming, process mapping and deep examinations of each step of the patient journey from pre-operative visit to post-operative discharge can have multiplicative benefits that extend from cost savings to maintaining the focus on improving quality and patient safety.

Comprehensive evaluation of liver resection procedures: surgical mind development through cognitive task analysis

BACKGROUND

Liver resection is a complex procedure for trainee surgeons. Cognitive task analysis (CTA) facilitates understanding and decomposing tasks that require a great proportion of mental activity from experts.

METHODS

Using CTA and video-based coaching to compare liver resection by open and laparoscopic approaches, we decomposed the task of liver resection into exposure (visual field building), adequate tension made at the working plane (which may change three-dimensionally during the resection process), and target processing (intervention strategy) that can bridge the gap from the basic surgical principle.

RESULTS

The key steps of highly-specialized techniques, including hanging maneuvers and looping of extra-hepatic hepatic veins, were shown on video by open and laparoscopic approaches.

CONCLUSIONS

Familiarization with laparoscopic anatomical orientation may help surgeons already skilled at open liver resection transit to perform laparoscopic liver resection smoothly. Facilities at hand (such as patient tolerability, advanced instruments, and trained teams of personnel) can influence surgical decision making. Application of the rationale and realizing the interplay between the surgical principles and the other paramedical factors may help surgeons in training to understand the mental abstractions of experienced surgeons, to choose the most appropriate surgical strategy effectively at will, and to minimize the gap.

A systematic review of intraoperative process mapping in surgery

Process mapping has been identified as a strategy to improve surgical efficiency but has been inconsistently applied in the literature and underutilised in surgical practice. In this journal, we recently described our utilisation of these approaches when applied to breast reconstruction. We showed that in surgery as complex as autologous breast reconstruction, process mapping can improve efficiency, and may improve surgical teaching, education and audit. The intraoperative period specifically is an area that can be applied not only to breast reconstruction, but to a much broader range of surgical procedures. A systematic review was undertaken of the databases Ovid MEDLINE, Allied and Complementary Medicine Database, Embase and PsychINFO. Manual searching of the references from articles identified was also conducted. Data items relating to the review aims were extracted from articles' methods, applications, and outcomes. A descriptive analysis was carried out to synthesise the information on the current usage of process mapping in the intraoperative period. Seventeen of 1,488 studies were eligible for review, with all of non-randomised study design. Studies had overlap in components of the intraoperative period to which process mapping was applied. Common areas of improvement were identified. Outcome measures were assessed in ten studies that implemented interventions based on the improvement areas to increase surgical efficiency. As such, process mapping has been used as part of larger quality improvement methods, albeit with inconsistent nomenclature, to improve surgical efficiency. While it has been applied to a range of surgical specialties, there is a lack of application to the surgical component of the intraoperative period. Greater consistency in the reporting and description of process mapping will enable further research for evidence of its benefits.

Defining the association between operative time and outcomes in children's surgery

INTRODUCTION

Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery.

METHODS

182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications.

RESULTS

Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28).

CONCLUSIONS

Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement.

LEVEL OF EVIDENCE

Level III.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Laparoscopic Right Hepatectomy by the Caudal Approach Versus Conventional Approach: A Comparative Study

BACKGROUND

Laparoscopic right hepatectomy (LRH) is increasingly performed for the treatment of many liver diseases. However, it remains a challenging procedure and is limited to highly specialized centers. Increasing the safety and efficacy of LRH is crucial. This study evaluated the safety and feasibility of the novel caudal approach (CDA) in LRH and in comparison with the conventional approach (CA).

METHODS

Of a total of 40 patients who underwent LRH between June 2007 and July 2015 at our center, 10 cases underwent the CDA, while 30 underwent the CA. Operative and postoperative outcomes were analyzed.

RESULTS

Clinical data and patient characteristics were comparable between the two groups. Only 1 patient required a laparoscopic-assisted procedure in the CDA group, while 14 patients were converted to laparotomy (n = 10) or laparoscopic-assisted procedures (n = 4) in the CA group, although the difference did not reach statistical significance (P = .060). However, the difference in conversion to laparotomy between the two groups was significant (P = .043). In addition, when considering 23 patients with malignancies, the median surgical margin was significantly greater in the CDA group (n = 6) (20 mm versus 10 mm; P = .023) than in the CA group (n = 17). Other operative and postoperative outcomes were similar between the two groups.

CONCLUSIONS

The CDA achieves safety and feasibility similar to that of the CA in LRH and requires relatively less conversion to laparotomy. In selected patients, the CDA offers an alternative option to the CA for LRH in experienced hands. Further studies with larger samples are warranted to evaluate the CDA.

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.