Laparoscopic General Surgery Research Articles

Factors associated with surgeon's perception of distraction in the operating room.

Distractions in the operating room (OR) can create stress among surgeons and lead to higher chances of errors and adverse events. The objective is to determine intraoperative factors that are associated with surgeons' perception of distraction. We conducted a prospective cohort study in 265 consecutive patients undergoing elective laparoscopic general surgery during the 2years after the implementation of a data capture system called the OR Black Box to identify intraoperative sources of distraction. At the end of each operation, human-factor surveys were administered to assess whether surgeons felt distracted. Using a multivariable logistic model, we determined which intraoperative sources of distraction were associated with the surgeons feeling distracted in the OR. The attending surgeon reported feeling distracted in 120 of 265 operations (45%). Auditory sources of distraction, such as the OR door opening occurred at a median of 41 times per case (interquartile range (IQR), 32-54). Cognitive distractions such as teaching (142 cases (54%)), device malfunction (91 (34%)), irrelevant conversations (72 (27%)), management of the next case (41 (15%)), and time pressure (22 (8%)) occurred in a significant number of operations. In a multivariable analysis, presence of irrelevant conversations (odds ratio 2.14, 95% confidence interval (CI) 1.16-3.94, p = 0.015) and patient history of previous abdominal surgery (odds ratio 2.2, 95% CI 1.18-4.1, p = 0.013) were independently associated with increased likelihood of the surgeons feeling distracted. Irrelevant conversation in the OR is a modifiable factor that was independently associated with surgeon's perception of distraction.

The effect of surrogate procedure volume on bariatric surgery outcomes: do common laparoscopic general surgery procedures matter?

A growing body of evidence shows that experience and acquired skills from surrogate surgical procedures may be transferrable to a specific index operation. It is unclear whether this applies to bariatric surgery. This study aims to determine whether there is a surrogate volume effect of common laparoscopic general surgery procedures on all-cause bariatric surgical morbidity. This was a population-based study of all patients aged ≥ 18 who received a bariatric procedure in Ontario from 2008 to 2015. The main outcome of interest was all-cause morbidity during the index admission. All-cause morbidity included any documented complication which extended length of stay by 24h or required reoperation. Bariatric cases included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Non-bariatric cases included three common laparoscopic general surgery procedures. 13,836 bariatric procedures were performed by 29 surgeons at nine centers of excellence. A reduction in all-cause morbidity was seen when bariatric surgeons exceeded 75 cases annually (OR 0.82, 95% CI 0.69-0.98, P = 0.023), with further reduction in increasing bariatric volume. However, the volume of non-bariatric surgeries did not significantly affect bariatric all-cause morbidity rates amongst bariatric surgeons, even when exceeding 100 cases (OR 0.84, 95% CI 0.61-1.12, P = 0.222). The present study suggests that experience and skills acquired in performing non-bariatric laparoscopic general surgery does not appear to affect all-cause morbidity in bariatric surgery. Therefore, only a surgeon's bariatric procedure volume should considered be a quality marker for outcomes after bariatric surgery.

Characterization of device-related interruptions in minimally invasive surgery: need for intraoperative data and effective mitigation strategies.

The burden of device-related interruptions is expected to increase as modern surgical practices adopt complex minimally invasive surgery devices. Currently, there is a paucity of empiric data that examined the nature of device-related interruptions using comprehensive intraoperative data. We performed a cross-sectional study of consecutive elective laparoscopic general surgery cases performed in one operating room (OR) at a referral center between April 2014 and April 2016. The included cases were directly observed using a comprehensive multiport data recorder called the OR Black Box. The data were synchronized, encrypted, and reviewed by expert surgeon assessors. The assessors characterized device-related interruptions that occurred during operations. The prevalence of the cases with device-related interruptions was calculated. Device-related interruptions were classified into a priori categories of (1) absent/wrong device; (2) improper assembly; (3) loss of sterility; (4) disconnection; and (5) device failure. In a cohort of 210 cases, 64 (30%) had at least one device-related interruption. Sleeve gastrectomy (52%) and oncologic gastrectomy (43%) procedures experienced the highest prevalence of device-related interruptions. Device failure was the most frequently chosen category with laparoscopic staplers implicated in more than half of these failures. Three failure modes were described for laparoscopic stapler, of which stapler malfunction (46%) was the most common. Device-related interruptions occurred frequently in the OR and could be characterized into one of the five categories. Understanding the nature of the device-related interruptions can help guide implementation of safety interventions and user training in the future.

Meta-analysis of perioperative outcomes of acute laparoscopic versus open repair of perforated gastroduodenal ulcers

Surgery is the treatment of choice for perforated peptic ulcer disease. The aim of the present review was to compare the perioperative outcomes of acute laparoscopic versus open repair for peptic ulcer disease. A systematic literature search was performed for randomized controlled trials (RCTs) published in PubMed, SCOPUS, and Web of Science. The search included eight RCTs: 615 patients comparing laparoscopic (307 patients) versus open peptic perforated ulcer repair (308 patients). Only few studies reported the Boey score, the Acute Physiologic Assessment and Chronic Health Evaluation score, and the Mannheim Peritonitis Index. In the RCTs, there is a significant heterogeneity about the gastric or duodenal location of peptic ulcer and perforation size. All trials were with high risk of bias. This meta-analysis reported a significant advantage of laparoscopic repair only for postoperative pain in first 24 hours (-2.08; 95% confidence interval, -2.79 to -1.37) and for postoperative wound infection (risk ratio, 0.39; 95% confidence interval, 0.23-0.66). An equivalence of the other clinical outcomes (postoperative mortality rate, overall reoperation rate, overall leaks of the suture repair, intra-abdominal abscess rate, operative time of postoperative hospital stay, nasogastric aspiration time, and time to return to oral diet) was reported. In this meta-analysis, there were no significant differences in most of the clinical outcomes between the two groups; there was less early postoperative pain and fewer wound infections after laparoscopic repair. The reported equivalence of clinical outcomes is an important finding. These results parallel the results of several other comparisons of open versus laparoscopic general surgery operations-equally efficacious with lower rates of wound infection and improvement in some measures of enhanced speed or comfort in recovery. Notably, the trials included have been published throughout a considerable time span during which several changes have occurred in most health care systems, not least a widespread use of laparoscopy and increase in the laparoscopic skills. Systematic review and meta-analysis, level III.

Live streaming of laparoscopic general surgery is a useful teaching tool

Results from a survey of medical students.

Routine blood group and antibody screening prior to emergency laparoscopy.

Introduction Studies show that rates of blood transfusion associated with general surgical laparoscopy are low. Currently, there are no national guidelines in the UK regarding blood group and antibody screening (G&S) for patients undergoing emergency laparoscopy. The aim of this study was to assess whether using G&S before emergency laparoscopic general surgery routinely is worthwhile by identifying rates of perioperative transfusion. Methods Data were collected retrospectively on all emergency laparoscopic procedures at a single district general hospital between January 2014 and 31 December 2016. Emergency laparoscopic general surgical cases were included and gynaecological cases excluded. Records were reviewed to ascertain whether G&S was performed, whether antibodies were detected and whether patients were transfused. Results A total of 562 emergency laparoscopic cases were performed. The median age was 28 years (range: 6-95 years). Laparoscopic appendicectomy (n=446), diagnostic laparoscopy (n=47) and laparoscopic cholecystectomy (n=25) were the most common procedures. Of the total patient cohort, 514 (91.5%) and 349 (70.1%) had a first and second G&S respectively while 30 (5.3%) had no G&S. Four patients (0.71%) had antibodies detected. One patient (0.18%) received a transfusion. This patient had undergone laparoscopic repair of a perforated duodenal ulcer and there was no major intraoperative haemorrhage but he was transfused perioperatively for chronic anaemia. Conclusions These results demonstrate a low rate of blood transfusion in emergency laparoscopic general surgery. The majority of these patients had a low risk of major intraoperative haemorrhage and we therefore argue that G&S was not warranted. We propose a more targeted approach to the requirement for preoperative G&S and the use of O negative blood in the event of acute haemorrhage from major vessel injury.

Why laparoscopists may opt for three-dimensional view: a summary of the full HTA report on 3D versus 2D laparoscopy by S.I.C.E. (Societ\xe0 Italiana di Chirurgia Endoscopica e Nuove Tecnologie)

BackgroundThree-dimensional view in laparoscopic general, gynaecologic and urologic surgery is an efficient, safe and sustainable innovation. The present paper is an extract taken from a full health technology assessment report on three-dimensional vision technology compared with standard two-dimensional laparoscopic systems.MethodsA health technology assessment approach was implemented in order to investigate all the economic, social, ethical and organisational implications related to the adoption of the innovative three-dimensional view. With the support of a multi-disciplinary team, composed of eight experts working in Italian hospitals and Universities, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaire and self-reported interviews, applying a final MCDA quantitative approach, and considering the dimensions resulting from the EUnetHTA Core Model.ResultsFrom systematic search of literature, we retrieved the following studies: 9 on general surgery, 35 on gynaecology and urology, both concerning clinical setting. Considering simulated setting we included: 8 studies regarding pitfalls and drawbacks, 44 on teaching, 12 on surgeons’ confidence and comfort and 34 on surgeons’ performances. Three-dimensional laparoscopy was shown to have advantages for both the patients and the surgeons, and is confirmed to be a safe, efficacious and sustainable vision technology.ConclusionsThe objective of the present paper, under the patronage of Italian Society of Endoscopic Surgery, was achieved in that there has now been produced a scientific report, based on a HTA approach, that may be placed in the hands of surgeons and used to support the decision-making process of the health providers.

Is nighttime laparoscopic general surgery under general anesthesia safe?

Fatigue and sleep deprivation can affect rational decision-making and motor skills, which can decrease medical performance and quality of patient care. The aim of the present study was to investigate the association between times of the day when laparoscopic general surgery under general anesthesia was performed and their adverse outcomes. All laparoscopic cholecystectomies and appendectomies performed at the emergency surgery department of a tertiary university hospital from 01. 01. 2016 to 12. 31. 2016 were included. Operation times were divided into three groups: 08.01-17.00 (G1: daytime), 17.01-23.00 (G2: early after-hours), and 23.01-08.00 (G3: nighttime). The files of the included patients were evaluated for intraoperative and postoperative surgery and anesthesia-related complications. We used multiple regression analyses of variance with the occurrence of intraoperative complications as a dependent variable and comorbidities, age, gender, body mass index (BMI), ASA score, and operation time group as independent variables. This revealed that nighttime operation (p<0.001; OR, 6.7; CI, 2.6-16.9) and older age (p=0.004; OR, 1.04; CI, 1.01-1.08) were the risk factor for intraoperative complications. The same analysis was performed for determining a risk factor for postoperative complications, and none of the dependent variables were found to be associated with the occurrence of postoperative complications. Nighttime surgery and older patient age increased the risk of intraoperative complications without serious morbidity or mortality, but no association was observed between the independent variables and the occurrence of postoperative complications.

0 + 5 Vascular Surgery Residents’ Operative Experience in General Surgery: An Analysis of Operative Logs from 12 Integrated Programs

Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training. Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied. A total of 12 integrated VS residency programs provided operative case logs for current residents. A total of 41 integrated VS residents in clinical years 2 through 5. During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035). 0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees.

Complications of low compared to standard pneumoperitoneum pressures in laparoscopic surgery for benign gynecologic pathology: a systematic review protocol.

BackgroundNo definite consensus has been established about the optimal pressure for artificial pneumoperitoneum when performing laparoscopic surgery. It has been postulated that lowering intra-peritoneal pressure levels while performing general laparoscopic surgery would lower surgical complications including post-operative pain, but data remain scarce about significant operative complications. Furthermore, such data is not available for gynecologic laparoscopy. The objective of this systematic review is to compare the frequency and nature of significant operative complications of lower and standard pneumoperiteoneal pressure levels in gynecologic laparoscopic surgery for benign indications.Methods/designWe will search PubMed, Embase, the Cochrane Library, randomised control trials registries, and reference lists of included articles. Randomised controlled trials comparing different intra-peritoneal pressure levels in women undergoing gynecologic laparoscopic surgery for a non-malignant indication will be eligible. Two reviewers will independently select and review references, extract data, and assess quality from included studies. We will use RevMan5 to calculate risk ratios and their 95 % confidence intervals to compare the frequency of complications according to intra-peritoneal pressure levels. We will perform sensitivity analyses to explore heterogeneity potentially due to various operative characteristics or characteristics of patients.DiscussionOur results will help identify the optimal intra-peritoneal pressure level in gynecologic laparoscopic surgery and determine if lowering intra-peritoneal pressure levels while trying to achieve lower levels of post-operative pain is an acceptable change of practice according to the frequency and nature of significant complications.Systematic review registrationPROSPERO: CRD42015020231Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0091-6) contains supplementary material, which is available to authorized users.

Italian experience in minimally invasive liver surgery: a national survey.

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5 days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.

Utilization and costs associated with robotic surgery in children

BackgroundTo evaluate utilization and costs associated with robotic surgery in children. Materials and methodsWe identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. ResultsThe number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. ConclusionsUse of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Medical students impact laparoscopic surgery case time

BackgroundMedical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. Materials and methodsData from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009–January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. ResultsSeven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. ConclusionsThis is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

The History of Laparoscopic General Surgery in the Caribbean

The first world witnessed a laparoscopic revolution in the 1990s. At the start, laparoscopic surgery was heavily criticized and ridiculed. Despite this, the specialty has blossomed where almost any procedure can be done laparoscopically with the now obvious tremendous benefit to the patients. The objective of this paper is to examine where the Caribbean is placed relative to the rest of the world in terms of laparoscopic surgery and to understand why we are here. The literature written on laparoscopy in the region was reviewed and contributions were taken from key surgeons in three main islands, Trinidad and Tobago, Barbados and Jamaica. Though the first laparoscopic cholecystectomy in the Caribbean, in most islands, took place in the early 1990s like the rest of the world, there was relative dormancy for at least a decade in Trinidad and Tobago and even longer in other islands with regards to implementing advanced procedures or increasing case volumes. Reasons for this included lack of funding, lack of operating time in public facilities, lack of information of the public and the medical fraternity but most importantly lack of trained laparoscopic surgeons. This last factor was proven to be the key one in Trinidad and Tobago in 2003, Jamaica 2005 and Barbados 2011/12, when the return of trained personel engineered the transition from basic to advanced laparoscopy Despite the delay of approximately 10 years in Trinidad and Tobago and 15 years in other islands, the return of trained surgeons has seen a rapid increase in case variety and volumes in laparoscopy. The wheels of motion of the laparoscopic revolution in the Caribbean have finally begun.

A comprehensive review of telementoring applications in laparoscopic general surgery

Incorporation of advanced laparoscopic procedures in the practice of institutions without respective experience is a significant impediment in the dissemination of minimally invasive techniques. On-site mentoring programs carry several cost-related and practical constraints. Telementoring has emerged as a practical and cost-effective alternative mentoring tool. The present study aimed to review the pertinent literature on telementoring applications in laparoscopic general surgery. A systematic review using the Medline database was performed. Articles reporting on clinical experience with telementoring applications in general surgery were included. Variations in methodology, study design, and operative procedures precluded cumulative outcome evaluation. Instead, a critical appraisal of current evidence was undertaken. Seventy-five articles were identified in the primary search, and ten studies were considered eligible. No randomized studies comparing on-site mentoring with telementoring were identified. The included studies reported on a total of 96 laparoscopic telementored procedures: 50 cholecystectomies, 23 colorectal resections, 7 fundoplications, 9 adrenalectomies, 6 hernia repairs, and 2 splenectomies. Completion of remotely assisted procedures was feasible in the vast majority of cases, whereas technical difficulties included video and audio latency with low transfer rates (<128 kbps) and inadequate guidance regarding the correct plane for dissection. Current evidence supports the feasibility and safety of telementoring programs in general surgery. Their clinical effectiveness as teaching alternatives to traditional mentoring programs remains to be further evaluated.

Portal Vein Thrombosis Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Portal vein thrombosis has been documented after laparoscopic general surgery and has been uncommonly observed after laparoscopic bariatric surgery. Among bariatric operations, the sleeve gastrectomy is being performed with ever-increasing frequency. Here we report the case of a man who presented with portal vein thrombosis after laparoscopic sleeve gastrectomy. A 41-y-old man underwent an uneventful laparoscopic sleeve gastrectomy for the treatment of morbid obesity, and presented on postoperative day 10 with nonfocal abdominal pain, nausea, vomiting, and leukocytosis. Computed tomography revealed portal vein thrombosis, which was found in the setting of Clostridium difficile colitis. Portal vein thrombosis may be identified with increasing frequency as the number of laparoscopic bariatric operations continues to increase. A high index of suspicion is necessary to diagnose this rare, but potentially lethal, complication.

Pioneering laparoscopic surgery in South-eastern Nigeria: A two-center general surgery experience

Background: Nigeria lags behind in the deployment of laparoscopic surgical services, even among the developing countries. In spite of the huge abundant human and materials resources at its disposal, public hospitals are still underfunded. However, some tertiary health institutions in our sub-region have been able to brave the odds to modernize their services. Aim: To review the early experiences of two general surgery units in laparoscopic surgery at two institutions in South-eastern Nigeria. Materials and Methods: A 3-year retrospective analysis of the laparoscopic general surgery operations carried out in Nnamdi Azikiwe University Teaching Hospital, Nnewi, and Federal Medical Centre Owerri, Nigeria, was done. Results: A total of 20 cases have been done in both hospitals: 9 laparoscopic cholecystectomies, 10 laparoscopic appendectomies, and 1 laparoscopic liver abscess drainage. There was no conversion to open surgery. The average duration of postoperative stay after cholecystectomy and appendectomy were 2.1 and 1.5 days, respectively. There was no major complication despite the challenging intraoperative adverse conditions. Conclusion: Laparoscopic surgery is safe in our region, but its evolution is still slow in our centers. Improved surgeon training and subsidization of the costs of the procedures may hold the key for accelerated development.

Effect of local anesthetics on postoperative pain and opioid consumption in laparoscopic colorectal surgery

Several studies have evaluated use of local anesthetic, specifically, administration of intraperitoneal anesthetic, during laparoscopic general surgery and gynecologic operations, with varying results. There have been no studies to determine the role of local anesthetic in laparoscopic colorectal surgery. This study evaluates the efficacy of subcutaneous and intraperitoneal anesthetic in reducing postoperative pain following common laparoscopic colorectal procedures, in patients managed with enhanced recovery care pathways. A single-institution retrospective cohort analysis of 172 patients who underwent common elective laparoscopic colorectal procedures was carried out. Over three consecutive time periods, patients were divided into three study arms, based on administration of local anesthetic. The first group received no local anesthetic (n = 66), the next received only subcutaneous bupivacaine (n = 67), and the final group received both subcutaneous bupivacaine and intraperitoneal lidocaine (n = 44). Pain scores, time in the postoperative care unit, and the amount of opioid pain medication consumed in the immediate postoperative period were quantified. There was no difference in pain scores reported between the three study arms, including upon arrival and upon leaving the recovery unit (P ≤ 0.086, P ≤ 0.166), and at 3, 6, 9, and 12 h postoperatively (P ≤ 0.332, P ≤ 0.142, P ≤ 0.155, P ≤ 0.872). There was no significant difference in the amount of postoperative opioid analgesia consumed between the three study arms on postoperative day 0 and on postoperative day 1 (P ≤ 0.365, P ≤ 0.458). There were no significant differences in the amount of time spent in the postoperative care unit, hospital stay, 30 day morbidity, or 30 day mortality between the three study arms. Use of local anesthetic does not influence postoperative opioid requirements or patients' subjective report of pain following laparoscopic colorectal procedures managed within enhanced recovery care pathways.

Global Evaluative Assessment of Robotic Skills: Validation of a Clinical Assessment Tool to Measure Robotic Surgical Skills

We developed and validated a standardized assessment tool for robotic surgical skills, and report its usefulness, reliability and construct validity in a clinical setting. The Global Evaluative Assessment of Robotic Skills is a tool developed by deconstructing the fundamental elements of robotic surgical procedures in consultation with expert robotic surgeons. Surgical performance was assessed during robot-assisted laparoscopic prostatectomy on a 5-point anchored Likert scale across 6 domains. An overall performance score was derived by summing the ratings in each domain. Expert surgeons and postgraduate year 4 to 6 urology residents were evaluated to determine construct validity. Assessments were completed by the attending surgeon, a trained observer and the operator. A total of 29 evaluations of 25 trainees and 4 attending surgeons were completed. Experts scored significantly higher on the assessment than novice operators (p = 0.004). Postgraduate year 4 and 5 residents scored significantly lower than the expert group (p <0.05) while no difference was observed between mean performance scores of postgraduate year 6 trainees and attending surgeons (p >0.05). The internal consistency of the assessment tool was excellent (Cronbach's α = 0.90 to 0.93). The overall assessment score ICC among raters was 0.80 (95% CI 0.65-0.90). The Global Evaluative Assessment of Robotic Skills is simple to administer and able to differentiate levels of robotic surgical expertise. This standardized assessment tool shows excellent consistency, reliability and validity. Further study is warranted to evaluate its usefulness for surgical education and the establishment of competency in robotic surgery.

Does speed matter? The impact of operative time on outcome in laparoscopic surgery

Controversy exists concerning the importance of operative time on patient outcomes. It is unclear whether faster is better or haste makes waste or similarly whether slower procedures represent a safe, meticulous approach or inexperienced dawdling. The objective of the present study was to determine the effect of operative time on 30-day outcomes in laparoscopic surgery. Patients who underwent laparoscopic general surgery procedures (colectomy, cholecystectomy, Nissen fundoplication, inguinal hernia, and gastric bypass) from the ACS-NSQIP 2005-2008 participant use file were identified. Exclusion criteria were defined a priori to identify same-day admission, elective procedures. Operative time was divided into deciles and summary statistics were analyzed. Univariate analyses using a Cochran-Armitage test for trend were completed. The effect of operative time on 30-day morbidity was further analyzed for each procedure type using multivariate regression controlling for case complexity and additional patient factors. Patients within the highest deciles were excluded to reduce outlier effect. A total of 76,748 elective general surgical patients who underwent laparoscopic procedures were analyzed. Univariate analyses of deciles of operative time demonstrated a statistically significant trend (p<0.0001) toward increasing odds of complications with increasing operative time for laparoscopic colectomy (n=10,135), cholecystectomy (n=37,407), Nissen fundoplication (n=4,934), and gastric bypass (n=17,842). The trend was not found to be significant for laparoscopic inguinal hernia repair (n=6,430; p=0.14). Multivariate modeling revealed the effect of operative time to remain significant after controlling for additional patient factors. Increasing operative time was associated with increased odds of complications and, therefore, it appears that speed may matter in laparoscopic surgery. These analyses are limited in their inability to adjust for all patient factors, potential confounders, and case complexities. Additional hierarchical multivariate analyses at the surgeon level would be important to examine this relationship further.