A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety

BACKGROUND

The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice.

METHODS

A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes.

RESULTS

Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability.

CONCLUSIONS

A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA)

BACKGROUND

A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe".

METHODS

A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe".

RESULTS

Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00.

CONCLUSIONS

The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

Perceived comfort and tool usability during robot-assisted and traditional laparoscopic surgery: a survey study

It is known that over half of previously surveyed surgeons performing Robot-Assisted Laparoscopic Surgery (RALS) and three-quarters of those performing Traditional Laparoscopic Surgery (TLS) experience intraoperative pain. This survey study aimed to expand upon the ongoing impact of that pain as well as perceived tool usability associated with TLS and RALS, for which considerably less documentation exists. A survey regarding the presence and impact, either immediate or ongoing, of intraoperative pain and Likert scale questions regarding tool usability was administered to TLS and RALS surgeons on the European Association for Endoscopic Surgery (EAES) mailing list. Prevalence statistics as well as trends based on biological sex and glove size were obtained from the 323 responses. Most respondents were right-handed European males (83-88%) with a medium glove size (55.8%). Moderate or severe shoulder symptoms were experienced by one-third of TLS surgeons. Twenty-one percent of RALS surgeons experienced neck symptoms that impacted their concentration. Small-handed surgeons experienced wrist symptoms significantly more frequently than large-handed surgeons, regardless of modality. RALS was associated with a significantly more optimal back and wrist posture compared to TLS. TLS surgeons reported increased ease with applying and moderating force while operating. These results suggest that intraoperative pain may be severe enough in many cases to interfere with surgeon concentration, negatively impacting patient care. Continuing to understand the relationship between tool usability and comfort is crucial in guaranteeing the health and well-being of both surgeons and patients.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes

BACKGROUND

Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery.

SETTING

Systematic review.

METHODS

A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included.

RESULTS

Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS.

CONCLUSION

This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Laparoscopic live donor nephrectomy: the preliminary experience

BACKGROUND

Recent improvements in video technology and surgical instrumentation have resulted in the application of minimally invasive techniques to many surgical procedures including splenectomy and adrenalectomy. Nephrectomy requires a long flank incision with division of abdominal musculature and possible subcostal nerve damage. Severe postoperative pain and a prolonged recuperative period may result, and the cosmetic outcome may not be satisfactory. A new surgical approach utilizing laparoscopic dissection and delivery of the kidney through a small incision was performed to circumvent these problems. The aim of this paper is to describe the technique of laparoscopic live donor nephrectomy (LLDN) and present the preliminary outcome.

METHODS

Over the 12-month period between May 1997 and April 1998, 16 donors underwent donor nephrectomy by a laparoscopic approach. The procedure was assessed with regard to its safety, feasibility and advantages over the open method.

RESULTS

All the nephrectomies were completed without conversion to an open procedure. The average postoperative pain score on a visual analogue scale of 1-10 was 2 in LLDN. The donors required 36 mg morphine on average over 36 h postoperatively. Postoperative stay averaged 3 days. One donor developed an infective complication along the wound drain tract which settled with adequate drainage and antibiotics. All the removed donor kidneys were transplanted with immediate good function. There were no surgical complications or graft losses. The recipients' serum creatinine was in the range of 96-181 mmol/L 3 months after transplantation.

CONCLUSIONS

Significant potential advantages of LLDN include less postoperative pain, shorter hospitalization and decreased recuperative time. This preliminary experience indicates LLDN to be effective in terms of safety and feasibility.

Laparoscopic-assisted colonoscopic polypectomy: technique and preliminary experience

BACKGROUND

The majority of colonic polyps found at endoscopy are suitable for diathermy snare excision via colonoscope. Due to location or size, some are deemed unsafe to treat in this manner and therefore require colectomy. This study describes the technique and early results of a laparoscopic-assisted colonoscopic polypectomy technique that can be used to manage such polyps and thereby avoid laparotomy and colectomy.

METHODS

Colonoscopy with simultaneous laparoscopy was utilized to locate the site of the polyp. The colon was mobilized, if required, and the polyp resected by electrosurgical snare via the colonoscope while the serosal aspect of the colon was monitored laparoscopically.

RESULTS

The technique has been tried successfully in six patients. Three polyps were in the cecum and three were within the left colon. The size of the polyps ranged from 3 to 7 cm. All polyps were benign on histological examination. The patients were discharged on the day following the procedure. There were no complications.

CONCLUSIONS

The combination of laparoscopy with colonoscopic resection of a select group of large polyps represents a safe alternative to colonic resection.

Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. An in vitro study

BACKGROUND

High-frequency (HF) electrocoagulation and cutting procedures produce smoke by high-temperature pyrolysis of tissues. As distinct from the experience of conventional surgery, electrosurgical smoke is produced in a closed gaseous environment during laparoscopic operations. As a result, toxic chemicals may be absorbed into the circulation. The effects of this absorption are not known. Furthermore, the chemical composition of electrosurgical smoke produced in an anoxic environment may be different from that produced in air.

METHODS

Smoke was produced in vitro by HF electrocutting of fresh porcine liver in helium, CO2, and air-saturated closed environments. Smoke samples were collected and analyzed by gas chromatography-mass spectrometry (GC-MS).

RESULTS

The chemical constituents of electrosurgical smoke produced in air, CO2, and helium were similar. To date, 21 chemicals, some highly toxic, have been identified in the electrosurgical smoke produced in a closed environment. These consist of hydrocarbons, nitriles, fatty acids, and phenols.

CONCLUSIONS

Electrosurgical smoke produced in a closed environment contains several toxic chemicals. The effects of these on cell viability, macrophage, and endothelial cell activation are not known but are being investigated. Meantime, measures to reduce smoke and evacuate it during endoscopic surgery are advisable.

Laparoscopic colectomy for cancer: a review

BACKGROUND

The success of laparoscopic cholecystectomy in providing patient benefits in the immediate postoperative period has led to laparoscopic techniques being used for many other intra-abdominal procedures. Colorectal resection for malignancy is one of the more contentious applications of this new technology, because the postoperative benefits are more subtle and the long-term onco logical results are as yet unknown.

METHODS

A review of the English-language literature was undertaken in order to collate and analyse all published series where 20 or more laparoscopic colectomies were performed. and where the indication for resection in the majority of cases was adenocarcinoma of the colon.

RESULTS

Laparoscopic colectomy for cancer can be performed safely by experienced surgeons, although there is a considerable learning curve for the procedure. The expected benefits of minimal access surgery are provided by laparoscopic colectomy, although to a lesser extent than that seen with other procedures. The oncological safety of the procedure is as yet unproven. It is clear that an equivalent resection can be performed, but not whether this translates to an equivalent recurrence and survival rate. Reports of isolated port site recurrences are of concern.

CONCLUSIONS

Early results of laparoscopic colectomy for cancer are encouraging, although the fate of this procedure rests with the analysis of the large multicentre prospective randomized trials currently under way, particularly with regard to the long-term recurrence and survival rates.

Total radiated power, infrared output, and heat generation by cold light sources at the distal end of endoscopes and fiber optic bundle of light cables

BACKGROUND

Skin burns and ignition of drapes have been reported with the use of cold light sources. The aim of the study was to document the temperature generated by cold light sources and to correlate this with the total radiated power and infrared output.

METHODS

The temperature, total radiated power, and infrared output were measured as a function of time at the end of the endoscope (which is inserted into the operative field) and the end of the fiber optic bundle of the light cable (which connects the cable to the light port of the endoscope) using halogen and xenon light sources.

RESULTS

The highest temperature recorded at the end of the endoscope was 95 degrees C. The temperature measured at the optical fiber location of the endoscope was higher than at its lens surface (p < 0.0001). At the end of the fiber optic bundle of light cables, the temperature reached 225 degrees C within 15 s. The temperature recorded at the optical fiber location of all endoscopes and light cables studied rose significantly over a period of 10 min to reach its maximum (p <0.0001) and then leveled off for the duration of the study (30 min). The infrared output accounted only for 10% of the total radiated power.

CONCLUSIONS

High temperatures are reached by 10 min at the end of fiber optic bundle of light cables and endoscopes with both halogen and xenon light sources. This heat generation is largely due to the radiated power in the visible light spectrum.

Cytotoxicity of electro-surgical smoke produced in an anoxic environment

BACKGROUND

The effect on cell viability of smoke produced during high-frequency electro-surgery has not been previously reported. The aim of this study was to produce smoke in vitro, in a closed environment similar to that encountered in minimal access surgery, and to test its cytotoxic effects on cultured cells.

METHODS

Pig liver was cut repeatedly with an electro-surgical hook knife, and the smoke generated was collected and equilibrated with cell culture medium. MCF-7 human breast carcinoma cells were exposed briefly to various dilutions of this medium and tested for clonogenicity.

RESULTS

Electro-surgical smoke produced in a helium environment reduced the clonogenicity of the MCF-7 human breast carcinoma cells in a dose-dependent manner, falling to 30% when the cells were exposed to undiluted medium for 15 minutes.

CONCLUSIONS

We conclude that electro-surgical smoke is cytotoxic. The sublethal effects at lower dilutions are currently being investigated.

Transcystic biliary decompression after direct laparoscopic exploration of the common bile duct

BACKGROUND

A purpose-designed transcystic common bile duct (CBD) decompression cannula is described for use as an alternative to T-tube insertion following laparoscopic direct CBD exploration. This permits safe primary closure of the choledochotomy.

METHODS

Following direct supraduodenal laparoscopic clearance of large common bile duct stones, the biliary decompression cannula is inserted percutaneously inside its peel-away sheet over a guide-wire into the CBD via the cystic duct. When in place, the cannula is secured to the cystic duct by two catgut extracorporeal Roeder knots and the choledochotomy is then closed. The terminal multiperforated S-shaped segment of the Cuschieri biliary decompression cannula prevents postoperative dislodgement.

RESULTS

Transcystic decompression of the extrahepatic biliary tract using the Cuschieri cannula has been used in 12 patients who underwent laparoscopic supraduodenal CBD exploration for large or occluding stones. There was no instance of postoperative dislodgement of the cannula and all patients had effective drainage of the common bile duct (average 300 ml bile per 24 h). The procedure was uncomplicated in all but one patient who developed self-limiting leakage from the CBD suture line in the early postoperative period. The median hospital stay after surgery was 4 days, with a range of 3 to 10 days. The cystic duct decompression cannula was capped and sealed under an occlusive dressing at the time of discharge. Removal of the cannula was carried out without any complications as a day case 11-16 days after surgery.

CONCLUSIONS

Transcystic biliary decompression is safe and effective. The experience with is use indicates that compared to T-tube drainage, transcystic decompression may accelerate recovery and reduce the hospital stay in patients following laparoscopic direct exploration of the CBD. Its insertion is less technically demanding than placing a T-tube through the choledochotomy. Transcystic decompression with complete primary closure of the CBD realizes the full benefits of the single-stage management of common bile duct calculi and permits confirmation of complete stone clearance after surgery.

HPLC determination of biologically active thiols using pre-column derivatisation with 5,5'-dithio-(bis-2-nitrobenzoic acid)

5,5'-Dithio-(bis-2-nitrobenzoic acid), Ellmans reagent (ESSE), is used as a pre-column derivatisation reagent for the determination of biologically active thiols by HPLC. D-penicillamine, N-acetyl-d-penicillamine, N-acetylcysteine, cysteine, captopril and thiomalic acid all give well resolved derivatives. The calibration graph and reproducibility (%R.S.D. +/- 1.3%) for the analysis of glutathione indicates that the method could be used for quantitative analysis. ESSE is widely used as a reagent in thiol determinations by electronic spectroscopy via the detection of the Ellmans anion (ES-) generated without any prior separation procedures. However, there are considerable reservations over its use for the spectrophotometric determination of thiols because of the possibility of side reactions which generate another Ellmans based species (ESO2-). The assay described determines the thiol as a derivatised mixed disulphide (ESSR) and since speciation between the anion ES- and the oxidation product ESO2- occurs it enables the process of oxidation to be monitored simultaneously.

Alcoholism: a controlled trial of "treatment" and "advice"

Two groups of alcoholics received either one counseling session or several months of in- and outpatient treatment. One year later there were no significant differences in outcome between the two groups.

The cohesiveness of alcoholism-complicated marriages and its influence on treatment outcome

One-hundred husbands, diagnosed as suffering from alcoholism, and their wives, were followed up twelve months after initial consultation and assessment. Follow-up information was complete in 89 cases. On the basis of both husband and wife accounts of the husband's drinking behaviour during the follow-up period, and their assessment of the drinking problem at twelve-months follow-up, 28 were classified as having a 'good' outcome and 29 as having a 'bad' outcome. In the remaining 32 cases outcome was considered 'equivocal'. A composite measure of marital cohesion was predictive of twelve-month outcome classification, cohesive marriages being significantly more likely to have a good outcome. The measure of marital cohesion was based upon husband and wife reports of mutual affection and of husband involvement in family tasks, favourable spouse perceptions and meta-perceptions, and optimism about the future of the marriage. Composite measures of dominance balance within the marriage were not predictive of outcome. Husband's job status, husband's self-esteem, and wife's reported hardship were not independent of marital cohesion, and were themseleves predictive of twelve-months outcome. When these variables were partially controlled it was found that marital cohesion remained predictive for husbands with relatively low status jobs and husbands with relatively low levels of self-esteem. It is an over-simplification to state that either the marriage, the spouse, or the severity of the patient's condition is alone the cause of variation in outcome. It is possible to integrate these findings with those of other studies on the influence of family variables on the outcom of conditions other than alcoholism. Together these studies suggest a general hypothesis linking a breakdown in the cohesiveness, or mutual rewardingness, of family relationships and unfavourable outcomes following treatment or consultation for psychological disorder.

Self-reported coping behavior of wives of alcoholics and its association with drinking outcome

The frequency of the use of coping behavior by wives of alcoholics was found to be related to their husband's drinking outcome. In general, a high frequency of coping behavior was associated with a poor outcome, but some components of coping behavior were more likely than others to be linked with a poor prognosis.

Alcoholics known or unknown to agencies: epidemiological studies in a London suburb

We present here some findings from a survey carried out in one (former) London borough, of the information known to one or more of a number of agencies such as courts, clergy, employers, doctors, etc. (we term these sources ‘reporting agencies', see Methodology Section 4), concerning those individuals who might have a drinking problem. The results will be interpreted in the light of a house-to-house sample survey which was conducted at the same time, and in part of that same area (Edwards et al., 1972a, b, c, d, 1973): the extent of overlap in case identification will be closely considered. The literature on epidemiology applied to alcoholism has been reviewed by one of us elsewhere (Edwards, 1973), and the relevance of epidemiology to planning the community's response to its drinking problems was discussed. In the present paper the application of those general arguments to the realities of a particular set of data will be tentatively explored.

Motivation for drinking among men: survey of a London suburb

Three hundred and six male subjects in a community survey reported on their ‘motivation for drinking’. Factor analysis revealed three major factors. Factor 1 relates to N (neuroticism) score, more extreme drinking, and likelihood of drink-related trouble. Factor 2 is associated with more privileged and factor 3 with less privileged class status.

Drinking problems among recidivist prisoners

The general relationship between alcohol and crime is reviewed, and five central methodological problems are identified relevant to prison population ‘alcoholism prevalence surveys’ as a prelude to a report of an investigation of 500 recidivist prisoners. The prevalence rate is shown to be highly dependent on the particular definition of ‘alcoholism’ which is employed. Long-term and short-term prisoner subgroups are compared, and similarities with a population of non-prisoner homeless men discussed. A ‘dependence score’ derived from an operant conditioning model of alcoholism correlates significantly with various measures of social instability.

The drunk in court: survey of drunkenness offenders from two London courts

A total of 151 men charged with drunkenness with or without aggravations were interviewed immediately after their appearance before the magistrates. The survey was conducted in two Metropolitan courts; one in an area frequented by vagrants, and the other in a mixed middle-class and working-class area.Few of the offenders were casual roisterers and the majority had a serious drinking problem. Half the offenders showed evidence of chemical dependence on alcohol as determined by morning shakes, morning relief drinking, amnesias, inability to stop drinking, and hallucinatory experiences.The majority of the offenders were suffering from gross social isolation.Existing ways of dealing with such men seem inadequate. A rehabitation service is needed, with hostel accommodation, and particular attention should be paid to first offenders.

Census of a reception centre

In the second half of the fourteenth century, the whole problem of poverty became in England for the first time a matter of government concern. The contractual relationship between landlord and villein which had prevailed during the Middle Ages, was breaking down, and the Black Death hastened this process. Statutes dealing with vagrancy and poverty were promulgated in 1349, 1351 and 1388: the able-bodied beggar was punished in the stocks and generally repression was the keynote, but despite harsh laws vagrancy increased. In a series of statutes from 1531–1601 the Tudor sovereigns initiated a system of local relief based on the Parish unit. In 1576, Houses of Correction were established: