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Humm GL, Peckham-Cooper A, Chang J, Fernandes R, Gomez NF, Mohan H, Nally D, Thaventhiran AJ, Zakeri R, Gupte A, Crosbie J, Wood C, Dawas K, Stoyanov D, Lovat LB. Surgical experience and identification of errors in laparoscopic cholecystectomy. Br J Surg 2023; 110:1535-1542. [PMID: 37611141 PMCID: PMC10564403 DOI: 10.1093/bjs/znad256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/29/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.
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Affiliation(s)
- Gemma L Humm
- Wellcome/Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, UK
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Adam Peckham-Cooper
- Leeds Institute of Emergency General Surgery, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Jessica Chang
- Department of General Surgery, Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - Roland Fernandes
- Department of General Surgery, East Kent Hospitals University Foundation Trust, William Harvey Hospital, Ashford, UK
| | - Naim Fakih Gomez
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Helen Mohan
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Deirdre Nally
- Department of General Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Roxanna Zakeri
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Anaya Gupte
- Department of General Surgery, University College London Hospital NHS Foundation Trust, University College Hospital, London, UK
| | - James Crosbie
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Christopher Wood
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Khaled Dawas
- UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Laurence B Lovat
- Wellcome/Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, UK
- UCL Division of Surgery and Interventional Science, University College London, London, UK
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Alim-Marvasti A, Jawad M, Ogbonnaya C, Naghieh A. Workforce diversity in specialist physicians: Implications of findings for religious affiliation in Anaesthesia & Intensive Care. PLoS One 2023; 18:e0288516. [PMID: 37611011 PMCID: PMC10446200 DOI: 10.1371/journal.pone.0288516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 06/29/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Minority ethnic identification between physician and patient can reduce communication and access barriers, improve physician-patient relationship, trust, and health outcomes. Religion influences health beliefs, behaviours, treatment decisions, and outcomes. Ethically contentious dilemmas in treatment decisions are often entangled with religious beliefs. They feature more in medical specialties such as Anaesthesia & Intensive Care, with issues including informed consent for surgery, organ donation, transplant, transfusion, and end-of-life decisions. METHODS We investigate diversity in religious affiliation in the UK medical workforce, using data from the General Medical Council (GMC) specialist register and Health Education England (HEE) trainee applications to medical specialties. We performed conservative Bonferroni corrections for multiple comparisons using Chi-squared tests, as well as normalised mutual-information scores. Robust associations that persisted on all sensitivity analyses are reported, investigating whether ethnicity or foreign primary medical qualification could explain the underlying association. FINDINGS The only significant and robust association in both GMC and HEE datasets affecting the same religious group and specialty was disproportionately fewer Anaesthesia & Intensive Care physicians with a religious affiliation of "Muslim", both as consultants (RR 0.57[0.47,0.7]) and trainee applicants (RR 0.27[0.19,0.38]. Associations were not explained by ethnicity or foreign training. We discuss the myriad of implications of the findings for multi-cultural societies. CONCLUSIONS Lack of physician workforce diversity has far-reaching consequences, especially for specialties such as Anaesthesia and Intensive Care, where ethically contentious decisions could have a big impact. Religious beliefs and practices, or lack thereof, may have unmeasured influences on clinical decisions and on whether patients identify with physicians, which in turn can affect health outcomes. Examining an influencing variable such as religion in healthcare decisions should be prioritised, especially considering findings from the clinician-patient concordance literature. It is important to further explore potential historical and socio-cultural barriers to entry of training medics into under-represented specialties, such as Anaesthesia and Intensive Care.
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Affiliation(s)
- Ali Alim-Marvasti
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Mohammed Jawad
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Chibueze Ogbonnaya
- Institute of Child Health, University College London, London, United Kingdom
| | - Ali Naghieh
- School of Public Policy, University College London, London, United Kingdom
- Middlesex University Business School, London, United Kingdom
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Stokes C, Haupt F, Becker D, Muthurangu V, von Tengg-Kobligk H, Balabani S, Díaz-Zuccarini V. The Influence of Minor Aortic Branches in Patient-Specific Flow Simulations of Type-B Aortic Dissection. Ann Biomed Eng 2023; 51:1627-1644. [PMID: 36967447 PMCID: PMC10264290 DOI: 10.1007/s10439-023-03175-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/19/2023] [Indexed: 03/28/2023]
Abstract
Type-B aortic dissection (TBAD) is a disease in which a tear develops in the intimal layer of the descending aorta forming a true lumen and false lumen (FL). Because disease outcomes are thought to be influenced by haemodynamic quantities such as pressure and wall shear stress (WSS), their analysis via numerical simulations may provide valuable clinical insights. Major aortic branches are routinely included in simulations but minor branches are virtually always neglected, despite being implicated in TBAD progression and the development of complications. As minor branches are estimated to carry about 7-21% of cardiac output, neglecting them may affect simulation accuracy. We present the first simulation of TBAD with all pairs of intercostal, subcostal and lumbar arteries, using 4D-flow MRI (4DMR) to inform patient-specific boundary conditions. Compared to an equivalent case without minor branches, their inclusion improved agreement with 4DMR velocities, reduced time-averaged WSS (TAWSS) and transmural pressure and elevated oscillatory shear in regions where FL dilatation and calcification were observed in vivo. Minor branch inclusion resulted in differences of 60-75% in these metrics of potential clinical relevance, indicating a need to account for minor branch flow loss if simulation accuracy is sought.
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Affiliation(s)
- C Stokes
- Department of Mechanical Engineering, University College London, London, UK
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, University College London, London, UK
| | - F Haupt
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - D Becker
- Clinic of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - V Muthurangu
- Centre for Translational Cardiovascular Imaging, University College London, London, UK
| | - H von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - S Balabani
- Department of Mechanical Engineering, University College London, London, UK
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, University College London, London, UK
| | - V Díaz-Zuccarini
- Department of Mechanical Engineering, University College London, London, UK.
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, University College London, London, UK.
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Dimitrakakis E, Lindenroth L, Dwyer G, Aylmore H, Dorward NL, Marcus HJ, Stoyanov D. An intuitive surgical handle design for robotic neurosurgery. Int J Comput Assist Radiol Surg 2021; 16:1131-1139. [PMID: 34028662 PMCID: PMC8260543 DOI: 10.1007/s11548-021-02402-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/05/2021] [Indexed: 12/28/2022]
Abstract
Purpose The expanded endoscopic endonasal approach, a representative example of keyhole brain surgery, allows access to the pituitary gland and surrounding areas through the nasal and sphenoid cavities. Manipulating rigid instruments through these constrained spaces makes this approach technically challenging, and thus, a handheld robotic instrument could expand the surgeon’s capabilities. In this study, we present an intuitive handle prototype for such a robotic instrument. Methods We have designed and fabricated a surgical instrument handle prototype that maps the surgeon’s wrist directly to the robot joints. To alleviate the surgeon’s wrist of any excessive strain and fatigue, the tool is mounted on the surgeon’s forearm, making it parallel with the instrument’s shaft. To evaluate the handle’s performance and limitations, we constructed a surgical task simulator and compared our novel handle with a standard neurosurgical tool, with the tasks being performed by a consultant neurosurgeon. Results While using the proposed handle, the surgeon’s average success rate was \documentclass[12pt]{minimal}
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\begin{document}$$80\%$$\end{document}80%, compared to \documentclass[12pt]{minimal}
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\begin{document}$$41\%$$\end{document}41% when using a conventional tool. Additionally, the surgeon’s body posture while using the suggested prototype was deemed acceptable by the Rapid Upper Limb Assessment ergonomic survey, while early results indicate the absence of a learning curve. Conclusions Based on these preliminary results, the proposed handle prototype could offer an improvement over current neurosurgical tools and procedural ergonomics. By redirecting forces applied during the procedure to the forearm of the surgeon, and allowing for intuitive surgeon wrist to robot-joints movement mapping without compromising the robotic end effector’s expanded workspace, we believe that this handle could prove a substantial step toward improved neurosurgical instrumentation.
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Affiliation(s)
- Emmanouil Dimitrakakis
- Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London (UCL), London, UK.
| | - Lukas Lindenroth
- Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London (UCL), London, UK
| | - George Dwyer
- Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London (UCL), London, UK
| | | | - Neil L Dorward
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Hani J Marcus
- Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London (UCL), London, UK
- UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London (UCL), London, UK
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