Surgeons' personality, characteristics and presence of meaning in life

BACKGROUND

Surgeons work long shifts and are frequently on call. Pressure to make quick and accurate decisions along with the responsibility of performing complex procedures contribute to surgeons' high stress-levels, anxiety and altered empathy level. We aimed to study surgeons' personality and meaning in life at two different centres.

METHODS

General surgeons completed 47 questions. Visual analogous scale-items with controlled internal consistency (Cronbach alpha) coefficients varying from .77 to .85 were used from the following scales: Global Measure of Perceived Stress; Hostility Questionnaire; Jefferson Scale of Physician Empathy; Meaning in Life Questionnaire-SF; Rosenberg Self-Esteem Scale; Spielberger State Anxiety Scale and Quality of Work life Scale. Multiple linear regression analyses, parametric or non-parametric tests were employed when considered adequate.

RESULTS

Fifty-four participants were recruited from 3 different levels of training. Gender differences in Anxiety, Physician Empathy and presence of meaning in life (MIL-P) were revealed. Junior trainees differed from senior trainees and consultants as regards MIL-P, Anxiety, Stress and work-related factors. The surgeons' self-rated self-esteem was work-related. Surgeons' Quality of Work Life was best predicted by Physician Empathy but also their self-rated Self-Esteem contributed significantly to the prediction. Surgeons' MIL-P was significantly predicted by Physician Empathy and State Anxiety.

CONCLUSION

Surgeons' current personality attributes might not apply to all of them. Female surgeons were more empathetic and felt more presence of meaning in life than male surgeons, and men were less anxious than female surgeons. Junior trainees experienced less anxiety than senior trainees but were more stressed than consultants. The most significant predictors of surgeons' personality were their experience of presence of meaning in life along with their level of empathy.

Anxiety and depression in surgeons: A systematic review

INTRODUCTION

The unique pressures of a surgical career put surgeons at particular risk of mental health conditions, including anxiety and depression. Surgeons have previously been shown to have a high prevalence of psychological distress. This study aimed to systematically review the prevalence of anxiety and depression amongst surgeons, and to identify factors that can modify the risk of anxiety and depression in surgeons.

METHODS

A 10-year systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines to identify citations related to the keywords "anxiety" OR "depression" AND "surgeon" in PubMed/Medline and ScienceDirect databases. Inclusion and exclusion criteria were applied to produce a final list of citations.

RESULTS

Thirty-one citations were included with a total of 11,399 participants. The median percentage of anxiety in surgeons was 20 with a range of 54.6%. While the median percentage of depression was 24 with a range of 59%. Risk factors associated with a higher risk of anxiety and depression include female gender, younger age, concurrent burnout, and occupational concerns regarding the COVID-19 pandemic. Protective factors include institutional support and a sense of social belonging.

CONCLUSIONS

There was a high prevalence of anxiety and depression amongst surgeons over the past decade. It is imperative to develop strategies to mitigate the effect of anxiety and depression in surgeons.

Robotic Appendicectomy: A review of feasibility

Acute appendicitis is one of the most common abdominal emergencies. There has been an increasing use of robotic abdominal surgery. However, it remains underutilised in emergency settings. This study aimed to systematically review robotic appendicectomy (RA) feasibility. A 20-year systematic review was performed, along with quality assessment. The research protocol was registered with PROSPERO. The search yielded 1,242 citations, including 9 articles. The mean quality score was 10.72 ± 2.56. The endpoints across the studies were rate of conversion to open surgery, length of hospital stay, blood loss and operative time. RA is a safe, feasible technique that can be performed in elective and emergency settings with minimal blood loss. The operative time and hospital stay were within acceptable limits. Robotic surgery's major drawback is its high cost and limited availability. Future studies evaluating RA with a focus on its application during emergencies and its cost-effectiveness are recommended.

Surgeon's narcissism, hostility, stress, bullying, meaning in life and work environment: a two-centered analysis

INTRODUCTION

Disruptive physician behaviour can affect patients' safety. If surgical trainees throughout higher education experience disruptive behaviour, impaired work-life may follow. Therefore, we aimed to study surgeons' level of narcissism (N), hostility, and stress in relation to their work environment and potential experience of bullying. We also scrutinized search for or presence of meaning in life.

METHODS

General surgeons in UK National Health Service from 2 hospitals participated with 3 levels of training: junior trainees (JT), senior trainees (ST), and consultants (CONS). Participants completed 52 VAS-formed questions plus demographics. Modified questionnaires were used for assessments of 'hostility', 'narcissism', meaning in life, quality of work-life, and bullying.

RESULTS

Altogether 33% of surgeons displayed narcissism and 22% could exhibit disruptive behaviour. MANOVA significant differences between low, medium, and high narcissism groups were revealed in hostility (p<.01), perceived stress (p=.001), and presence of meaning in life (p<.05). Regression analyses explained hostility both by N-scale (p=.000) and 'being bullied during training'(p=.009) but negatively by 'presence of meaning in life'(p=.004). Surgeons' perceived stress was explained both by N-scale (p=.000) followed by 'seeing others bullied during training (p=.000) and negatively by 'working extra days beyond schedule' (p=.007). The presence of meaning in life was explained mostly by good beneficial stress (p= .000) but negatively both by 'doing extra work beyond schedule' (p= .016) and hostility (p= .003).

CONCLUSION

Surgeons may exhibit disruptive behaviour in a challenging situation. The narcissim-scale was the best predictor of hostility and perceived stress. Being bullied during surgical training predicted hostility. Seeing others being bullied during surgical training predicted stress. Beneficial stress is explained best by surgeons' experience of the presence of meaning in life.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Racial discrimination in surgery: A systematic review

INTRODUCTION

Racial/ethnic discrimination indicates the stereotyped or unkind conduct of superiority towards other persons based on their race or skin color. The UK General Medical Council published a statement supporting zero-tolerance approach to racism in the workplace. We aimed to systematically review racial discrimination in surgery and answer the following questions: (1) Does racial/ethnic discrimination in surgery exist in citations from the last 5 years. (2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery?

METHODS

The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. Search terms were 'racial discrimination and surgery', 'racism OR discrimination AND surgery', 'racism OR discrimination AND surgical education'. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE.

RESULTS

A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. There was evidence of racial discrimination in the last 5 years and the results were justified on strong scientific evidence constituting the basis for evidence grade I. The second question's answer was 'yes' which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II.

CONCLUSION

There was sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual as well as on the level of the surgical team performance. The existence of the discussed problems must be managed in more countries with diverse healthcare systems.

Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in clinical practice

Background.

Acute cutaneous abscess is a common surgical condition that mostly requires incision and drainage. Despite this, there is no standardized national or international guidance on post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice for post-operative antibiotics prescription for cutaneous abscesses in a UK university teaching hospital.

Methods.

Retrospective data collection for emergency general surgical admissions for a period of 6 months was carried out. All patients with cutaneous abscesses were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, co-morbidities and complications, including local (cellulitis, necrosis) and systemic (e.g sepsis), were studied. Approval for access to patient data was granted by the local clinical governance department prior to the commencement of this study. Computations were performed using IBM SPSS version 26. Chi square (X²), Pearson correlation (r), one or two samples t-test (one or two tailed) were applied.

Results.

A total of 148 patients were included. The mean age was 40 years (55 % males). The most common site of abscess was perianal (27.7 %), followed by pilonidal (20.3 %) and axilla (16.9 %). A total of 107 (73 %) were managed surgically with incision and drainage, and of these 92 (86 %) were managed within 24 h. Altogether, 83 (76 %) were prescribed post-operative antibiotics, while only 25 (23 %) had indications. The most used post-operative empirical antibiotics was co-amoxiclav (59 %). There was a significant relationship between ‘abscess site’ × ‘antibiotics’ [X² (36)=54.8, P=0.023]. A total of 103 patients’ average duration of post-operative antibiotics was 7.2 (sd 2.9) days. Ten patients subject to readmission spent an average of 8.4 (sd 3.8) days on antibiotics.

Conclusions.

There were variations in clinical practice regarding post-operative antibiotic prescription for cutaneous abscesses. Research is required in the future in cooperation with microbiologists to develop a standardized evidence-based treatment protocol for the management of such a common surgical condition.

Abdominal hernia mesh repair in patients with inflammatory bowel disease: A systematic review

Background

Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons’ decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications.

Method

A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE’s recommendations. The research protocol was registered with PROSPERO (CRD42021247185).

Results

The present systematic search resulted in 11,243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate quality. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn’s disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition biological mesh, and gastrointestinal concomitant procedure.

Conclusion

Patients with IBD were subject, more so than controls to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques, and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.

EP-20 Postoperative music, a non-pharmacological pain relief: a randomized controlled trial

Aims

Postoperative moderate to severe pain disrupts patients’ sleep and affects their quality of life. Non-pharmacologic pain relief such as music therapy were considered beneficial. We therefore evaluated preferred type of music as pain relief in patients with abdominal surgery in a non-UK teaching hospital.

Methods

Patients undergoing open abdominal operations were included. Patients with laparoscopic or rectal surgery and/or spinal or epidural anesthesia were excluded. Routine postoperative analgesics were used. Demographic variables were recorded and VAS pain scale (0–10 most severe pain) was assessed in first day postoperative. Patients or their relatives gave informed consent.

Results

Sixty patients (Md age 39 years) were included; 30 patients allocated in experimental group who listened to preferred music using headphones (20 min) vs Control group used headphones without music.

Fisher's exact test and independent t-tests were computed. The pain intensity decreased from 6.94 (SD .13) to 6.21 (SD .21) in the control group (n.s,) and in the experimental group from 7.06 (SD .31) to 3.25 (SD .21), (p &lt;.0001, 2-tailed) with no significant difference between the two groups before intervention. Pain intensity in experimental group decreased due to the intervention. There was a significant difference in pain intensity between the experimental and control groups after music therapy (p &lt; .001, 2-tailed).

Conclusion

The patients who listened to preferred music after surgery, experienced less pain compared to their controls. A long-term follow-up with larger sample size may conform the efficacy of post-operative music as a pain-relief in UK settings.

Acute surgical admissions at the end of life-an analysis of non-operative hospital deaths

BACKGROUND

Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission.

METHODS

This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis.

RESULTS

A total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death.

CONCLUSION

Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.

TP8.2.6 The effect of checklists on the surgical performance during laparoscopic cholecystectomy: A systematic review

Aims

Laparoscopic cholecystectomy (LC) is known to be one of the most widely performed general surgical operations. However, it is still associated with an increased incidence and severity of complications especially during the period of a surgeon’s proficiency-gain curve. Certain complications could be prevented by decreasing the incidence and consequences of surgeon errors. We aimed to systematically review the use of checklists during LC and their effect on the surgical task performance.

Methods

A systematic review was performed in compliance with the PRISMA guidelines. A search was carried out on PubMed, ScienceDirect and the Cochrane-Library databases. English language articles published to November 2020 were included in this study. The terms included: ‘Checklist and laparoscopic cholecystectomy’, ‘checklist and laparoscopic surgery’, ‘checklist and cholecystectomy’ and checklist and minimally invasive surgery’’. MERSQI score was applied for quality assessment. The research protocol was registered with PROSPERO register (CRD42021209118).

Results

The results of the systematic search resulted in 8862 citations, of which 23 relevant citations were assessed for eligibility. A final 9 articles were included in this study. The endpoints were equipment-related-risk events, numbers and types of adverse events, rate of conversion to open cholecystectomy, team communication and coordination, the number of consequential and inconsequential errors. The positive effect of checklists on the performance during LC was supported with 5 high-quality studies.

Conclusion

The effect of checklists application during LC showed a significant improvement of the surgical task performance by decreasing the number of surgeons’ errors. We envisage the routine use of checklists during LC.

EP.WE.83Surgeon’s Acute Stress Disorder During Covid-19: A Case Study with E-Mail Therapy

Aims

A higher surgical trainee combatted patients’ deaths and disasters from COVID-19. The trainee treated daily COVID-19-positive patients. In May 2020, he recognized symptoms of COVID-19. Throat swab test confirmed the suspicion of contagion. We aimed to study the acute stress disorder (ASD) during the COVID-19 pandemic in the surgical trainee.

Methods

The case self-isolated for 2 weeks with an intensifying fear of health deterioration. The case’s isolation and feelings of being in poor health, opened for an e-mail therapy. Sixty open-ended questions were answered in Socratic-maieutic style. The finding of severe (ASD) was validated and confirmed by use of the National Stressful Events Survey Acute Stress Disorder Short Scale. The mail therapy continued until the case felt that the crisis had faded. After 10 weeks a follow up was completed A, B and C times for 7 issues: death anxiety, worries about family after own death, chest pressure, other physical symptoms, stress, depression, other psychological symptoms

Results

Our hypothesis was termed “acute stress reactions”. Our case’s ASD was categorized as “severe”. Friedman test was applied for the related groups A, B and C, indicating an overall symptom improvement (p &lt; .001) which by Page’s L trend test disclosed a significant trend in symptom cutback from A to C (p &lt; .001).

Conclusion

The surgeons’ awareness is required that in some cases, the psychological symptoms escalate during isolation and quarantine periods and may even override the physical awkwardness, urging us to address both types of discomfort simultaneously and intensely.

SP6.1.8Fundus-first laparoscopic cholecystectomy for complex gallbladders: A systematic review

Aims

Retrograde ‘fundus-first’ cholecystectomy is when the dissection starts from the fundus of the gallbladder to the infundibulum, in case structures of Calot's triangle cannot be identified. Although feasible in laparoscopic cholecystectomy, it remains an underutilized approach. We aimed to systematically review the fundus-first laparoscopic cholecystectomy and study its safety and feasibility.

Methods

A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect and Cochrane-Library for articles published from 2010 to 2020. Search keywords included ‘retrograde cholecystectomy’, ‘fundus-first cholecystectomy’ and ‘fundus-down cholecystectomy’. Quality assessments were applied using the Medical Education Research Quality Instrument (MERSQI) score. The protocol was registered with PROSPERO register.

Results

A total of 3503 studies formed the base for evidence evaluations. 12 studies with 1978 fundus-first cholecystectomies were assessed. Three citations were scored high and 5 moderate quality. Endpoints included blood loss, rate of conversion to open, bile duct injury, gallbladders perforations, postoperative pain and hospital stay. Nine studies provided both strong and moderate scientific evidence for a positive outcome of the fundus-first approach.

Conclusion

The fundus-first cholecystectomy was associated with a reduced need for intraoperative cholangiography, shorter operating time, lower incidence of intra-operative complications, bile duct injury and reduced incidence of conversion to open cholecystectomy.

TP9.2.7Acute Surgical Admissions at the End of Life: an Analysis of Deaths in Non-operatively Managed Patients

Aims

Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission.

Methods

This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis.

Results

72 patients were included. 68.1% of patients died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p &lt; 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death.

Conclusion

Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.

EP.FRI.537 Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in Clinical Practice or lack of guidelines

Aims

Acute cutaneous abscess is a common surgical condition which mostly require incision and drainage. Despite this, there is no standardised national or international guidance on the post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice of the post-operative antibiotics prescription for cutaneous abscesses in a University teaching hospital in London.

Methods

A retrospective data collection of emergency general surgical admissions for a period of six months from July to December 2020 was carried out. All patients with superficial skin abscess were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, Co-morbidities, local and systemic complications were studied.

Results

A total of 149 patients presented during this period. Mean age was 40 (54% were male). Most common site of abscess was perianal (24%), followed by pilonidal, axilla, back, gluteal, neck, abdominal wall and groin. At total of 108 (72.5%) were managed surgically with incision and drainage, 70 (65%) got antibiotics and only 23 (33%) had indications for it (i.e. diabetic, immunocompromised, sepsis, cellulitis, MRSA carriage) = (χ2[1] =22.03, p&lt;.0001).

Co-amoxiclav was the most common post-operative empirical antibiotic prescribed in 61% of the patients. 

Conclusions

This study has identified significant variation in clinical practice regarding post-operative antibiotic usage in superficial abscesses. Further research is required in cooperation with microbiologists to develop standardised evidence-based treatment protocol for management of such common surgical condition.  

EP.FRI.535 A clinical audit of post-operative antibiotics prescription in uncomplicated perianal abscesses

Aims

Management of perianal abscesses continues to revolve around prompt surgical drainage. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines state that all patients should have incision and drainage within 24 hours and antibiotics are not indicated in routine uncomplicated perianal abscesses. We aimed to study the antibiotics prescription after surgical drainage in a London university teaching hospital against the national standard. 

Methods

A single-centred retrospective analysis of all emergency surgical admissions for incision and drainage of perianal abscess was carried out for a 6 month period. Patients’ demographics, Co-morbidities, local and systemic complications and readmissions were studied. 

Results

A total of 36 patients, (mean age 43, 64% males) were included in this study, 21 received incision and drainage without antibiotics prescription, while 15 received empirical post-operative antibiotics. Indications for antibiotic therapy in this group included diabetes, immunocompromise, local complications (necrosis, cellulitis) and recurrence. There was no clear indication for antibiotics in 60% of patients who received them. 86% of patients had surgical drainage within 24 hours of presentation. One patient was readmitted for a second drainage 3 months later. Most common empirical agent used was co-amoxiclav (53%), followed by (33%) combination of co-amoxiclav and metronidazole. 

Conclusion

Although surgical drainage was generally carried out in timely manner according to guidance, there was excessive post-operative antibiotic prescriptions. Increase awareness of guidelines is required to improve antibiotic stewardship in these surgical patients in order to avoid unnecessary drugs’ prescription.

The innate aptitude's effect on the surgical task performance: a systematic review

Surgery is known to be a craft profession requiring individuals with specific innate aptitude for manipulative skills, and visuospatial and psychomotor abilities. The present-day selection process of surgical trainees does not include aptitude testing for the psychomotor and manual manipulative skills of candidates for required abilities. We aimed to scrutinize the significance of innate aptitudes in surgical practice and impact of training on skills by systematically reviewing their significance on the surgical task performance. A systematic review was performed in compliance with PRISMA guidelines. An initial search was carried out on PubMed/Medline for English language articles published over 20 years from January 2001 to January 2021. Search strategy and terms to be used included ‘aptitude for surgery’, ‘innate aptitude and surgical skills, ‘manipulative abilities and surgery’, and ‘psychomotor skills and surgery’. MERSQI score was applied to assess the quality of quantitatively researched citations. The results of the present searches provided a total of 1142 studies. Twenty-one studies met the inclusion criteria out of which six citations reached high quality and rejected our three null hypothesis. Consequently, the result specified that all medical students cannot reach proficiency in skills necessary for pursuing a career in surgery; moreover, playing video games and/or musical instruments does not promote skills for surgery, and finally, there may be a valid test with predictive value for novices aspiring for a surgical career. MERSQI mean score was 11.07 (SD = 0.98; range 9.25–12.75). The significant findings indicated that medical students with low innate aptitude cannot reach skills necessary for a competent career in surgery. Training does not compensate for pictorial-skill deficiency, and a skill is needed in laparoscopy. Video-gaming and musical instrument playing did not significantly promote aptitude for microsurgery. The space-relation test has predictive value for a good laparoscopic surgical virtual-reality performance. The selection process for candidates suitable for a career in surgery requests performance in a simulated surgical environment.

Laparoscopic surgery in patients with cystic fibrosis: A systematic review

INTRODUCTION

Laparoscopic surgery may be advantageous for cystic fibrosis (CF) patients because it leads to fewer complications than open surgery. However, it could still lead to pulmonary and cardiovascular complications in CF patients. We aimed to systematically review the use of laparoscopic surgery in CF patients.

METHODS

A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect, EMBASE, and Google Scholar, with "cystic fibrosis and laparoscopic surgery" and "cystic fibrosis and minimally invasive surgery" used as the search terms. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied. The protocol was registered with the PROSPERO register.

RESULTS

Six studies met the predetermined inclusion criteria; accordingly, two studies provided high-quality evidence and four provided moderate-quality evidence. The interrater correlation was convincing (r_s  = .95, P = .02, two-tailed). Therefore, three quantitative studies and three qualitative studies were assessed and evidence-graded in accordance with the GRADE protocol.

CONCLUSION

The benefits of laparoscopic surgical interventions for patients with CF were supported with good evidential value and recognized as a safe and suitable surgical option.

Laparoscopic Surgery and the debate on its safety during COVID-19 pandemic: A systematic review of recommendations

INTRODUCTION

The transmission of COVID-19 virus since the outbreak of viral pneumonia due to SARS-CoV-2 gave rise to protective operative measures. Aerosol generating procedures such as laparoscopic surgery are known to be associated with increased risks of viral transmission to the healthcare workers. The safety of laparoscopy during the pandemic was then debated. We aimed to systematically review the literature regarding the safe use of laparoscopy during COVID-19.

METHODS

We performed a systematic search using PubMed and ScienceDirect databases from inception to 1st May, 2020. The following search terms were used: ''laparoscopic surgery and COVID-19''; ''minimally invasive surgery and COVID-19''. Search items were considered from the nature of the articles, date of publication, aims and findings in relation to use of laparoscopic surgery during COVID-19. The study protocol was registered with PROSPERO register for systematic reviews (CRD42020183432).

RESULTS

Altogether, 174 relevant citations were identified and reviewed for this study, of which 22 articles were included. The analysis of the findings in relation to laparoscopic surgery during the pandemic were presented in tabular form. We completed the common recommendations for performing laparoscopy during the COVID-19 pandemic in forms of pre-, intra- and postoperative phases.

CONCLUSION

There is no scientific evidence to date for the transmission of COVID-19 by laparoscopic surgery. Laparoscopy can be used with precautions because of its benefits compared to open surgery. If safe, conservative management is the primary alternative during the pandemic. We concluded that recommended precautions should be respected while performing laparoscopy during the pandemic.

The influence of music on the surgical task performance: A systematic review

INTRODUCTION

Music is commonly played in operating theatres. Music was shown to diminish stress of the surgical team along with reducing the patient's anxiety before surgery. On the other hand, it has been revealed that music might give rise to negative effects of divided attention causing distraction in surgical routines. Therefore, we aimed to systematically review the effect of music on the surgeon's task performance.

METHODS

A systematic review was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. A literature search using PubMed/Medline, ScienceDirect and Google Scholar, was performed by means of the search terms: "music and operating theatre", as well as "music and surgery". The search was limited to citations in English from year 2009-2018. Search items were considered from the nature of the articles, date of publication, forum of publication, aims and main findings in relation to use of music in operating theatres. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied. Studies were included based on predetermined inclusion criteria where after the papers' quality assessments and evidence grading were completed by two independent reviewers. The protocol was registered with the PROSPERO register of systematic reviews.

RESULTS

Out of 18 studies that formed the base for evidence evaluations, 6 studies were assessed as having high quality and 8 studies of moderate quality. Five studies, provided both strong and moderate scientific evidence for a positive effect of music on surgeon's task performance. In contrast, strong scientific evidence for a negative effect of music on surgeon's task performance also was revealed in 2 high-quality studies. Nevertheless, the positive effect of music on the surgical task performance was significantly higher when compared to its negative effect (p < 0.0001).

CONCLUSION

Certain music elements affect the surgical task performance in a positive or negative way. The total and significant outcome of the present study was that the positive effect of music on surgeon's task performance, overrides its negative effect. Classic music when played with a low to medium volume can improve the surgical task performance by increasing both accuracy and speed. The distracting effect of music should also be put in consideration when playing a loud or high-beat type of music in the operating theatres.

The Application of a Performance-Based Self-Administered Intra-procedural Checklist on Surgical Trainees During Laparoscopic Cholecystectomy

Introduction

Surgical checklists are in use to reduce errors for safer surgery. We aimed to study the effect of a previously designed performance-based self-administered intra-procedural checklist on the performance of trainees during elective laparoscopic cholecystectomy.

Methods

Twenty-four laparoscopic cholecystectomies were enrolled into the study. Six surgical trainees each performed four procedures, two without the checklist and directly followed by two procedures with the checklist. A soft beeping sound reminded each trainee to apply the checklist every 4 min during the procedures. The unedited videos were analysed using the human reliability analysis technique for the number of consequential errors, number of interventions by the trainer, number of instrument movements and time execution. The trainees’ satisfaction was assessed on a 5-point Likert scale questionnaire. Nonparametric test was used for data analysis. p value was defined as significant when p < 0.05.

Results

Participants performed statistically better with the application of the checklist compared to when no checklist was used, respectively: Median [IQR] total number of errors 1.51 [0.80] versus 3.84 [1.42] (p = 0.002) and consequential errors 0.20 [0.12] versus 0.45 [0.42] (p = 0.005), and the number of instrument movements per time decreased from 11.90 [5.34] to 10.38 [5.16] (p = 0.04). With the introduction of the checklist, the number of interventions by the trainer per time decreased from 2.79 [1.85] to 0.43 [1.208] (p = 0.003). The trainees satisfaction score was 4.5 [1] for the first question, 4 [1] for the second question and 4 [2] for the third question.

Conclusion

The self-administered intra-procedural checklist improved the performance of surgical trainees and decreased the number of interventions by the trainer during laparoscopic cholecystectomy. The trainees were generally satisfied using the checklist during the procedures.

A study of the visual symptoms in two-dimensional versus three-dimensional laparoscopy

AIM

There are reports of visual strains and associated symptoms when operating in a 3D laparoscopic environment. We aimed to study the extent of visual symptoms seen in 3D versus conventional 2D imaging in volunteers performing laparoscopic tasks and study the effect of eye exercises on 3D laparoscopy.

METHODS

Twenty four consented laparoscopic novices were required to undergo a visual acuity test (Snellen chart) and eye deviation test (Maddox Wing). A battery of specific isolated laparoscopic tasks lasting 30 min was developed to test their ability to detect changes in 2D and 3D environments separately. Before and after the 2D and 3D laparoscopic tasks, subjects were asked to complete a standardised questionnaire designed to scale (from 0 to 10) their visual symptoms (blurred vision, difficulty in refocusing from one distance to another, irritated or burning eyes, dry eyes, eyestrain, headache and dizziness). Participants who underwent 3D laparoscopic tasks were randomized into two groups, those who received two minutes eye exercises before performing the tasks and those who didn't. Independent t-test was used for the statistical analysis of this study.

RESULTS

Visual symptoms and eye strain were significant in 2D (p < 0.01) and difficulty in refocusing from one distance to another was significant in 3D laparoscopic imaging (p < 0.05). There was no significant effect of the simple eye exercises on relieving the visual symptoms in the 3D group.

CONCLUSION

Visual symptoms were present in both 2D and 3D imaging laparoscopy. Eye strain was prominent in 2D imaging, while difficulty in refocusing from one distance to another was prominent in 3D. Eye exercises for 3D visual symptoms did not bring any significant improvement.

The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons

Surgical checklists are in use as means to reduce errors. Checklists are infrequently applied during emergency situations in surgery. We aimed to study the effect of a simple self-administered performance-based checklist on the laparoscopic task when applied during an emergency-simulated scenario. The aviation checklist for unexpected situations is commonly used for simulated training of pilots to handle emergency during flights. This checklist was adopted for use as a standardised-performance-based checklist during emergency surgical tasks. Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into two equal groups; those using the checklist that was applied once every 20 s (checklist group) and those without (control group). The checklist group performed significantly better in 5 out of 7 technical factors when compared to the control group: right instrument path length (m), median (IQR) 1.44 [1.22] versus 2.06 [1.70] (p = 0.029), right instrument angular path (degree) 312.10 (269.44 versus 541.80 [455.16] (p = 0.014), left instrument path length (m) 1.20 [0.60] versus 2.08 [2.02] (p = 0.004), and left instrument angular path (degree) 277.62 [132.11] versus 385.88 [428.42] (p = 0.017). The checklist group committed significantly fewer number of errors in the application of haemostatic clips, 3 versus 28 (p = 0.006). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p = 0.724) and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p = 0.165). The performance-based intra-procedural checklist significantly enhanced the surgical task performance of novices in an emergency-simulated scenario.

The effect of a simple intraprocedural checklist on the task performance of laparoscopic novices

BACKGROUND

Surgical checklists are used for error reduction. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to study the effect of a self-administered checklist on the laparoscopic task performance of novices during a standardized task.

METHODS

Twenty novices were randomized into 2 equal groups, those receiving paper feedback (control group) and those receiving paper feedback and the checklist (checklist group). Subjects performed laparoscopic double knots, repeated over 5 separate stages. Human reliability assessment technique was used for error analysis.

RESULTS

2,341 errors were detected during the 5 stages. During the first stage, the errors were not significantly different between the 2 groups. The checklist group committed significantly fewer errors as compared with the control group during all the later 4 stages (P < .01).

CONCLUSIONS

The simple intraprocedural checklist significantly improved the laparoscopic task performance and the learning curve of laparoscopic novices.