Surgeon Feedback Research Articles

Intraoperative optical coherence tomography using the RESCAN 700: preliminary results from the DISCOVER study

Significant integrative advances are needed for intraoperative optical coherence tomography (iOCT) to achieve widespread use across ophthalmic surgery. A surgeon feedback system that provides microscope integration, heads-up display and foot...

Visualisation of contrast-enhanced intraoperative optical coherence tomography with indocyanine green

Optical coherence tomography (OCT)-based visualisation of ophthalmic anatomy has transformed the clinical practice of ophthalmology. The translation of OCT into the surgical theatre is currently being actively researched and may...

The clinical significance of rapid prototyping technique in complex spinal deformity surgery—Case sharing and literature review

Treatment of complex severe spinal deformities, such as scoliosis with a Cobb angle greater than 90°, critical spinal kyphosis, or vertebral and rib deformity with impaired lung capacity, remains a great challenge. Preoperative image studies including plain film radiography, computed tomography, and magnetic resonance imaging provide only two-dimensional (2D) images and limited information about these severe deformities. In addition, these studies cannot directly offer visual or tactile feedback for surgeons and patients. On the contrary, the rapid prototyping (RP) technique provides surgeons with full-scale, 3D models, which make more accurate and more direct morphometric information of the complex spinal deformity obtainable. In this study, we intend to share our experience with the RP technique in pediatric spine deformity cases and to provide a literature review. In our study, two patients with severe spinal deformity were included. A real-size spinal model was produced for each patient on the basis of contiguous computer tomography with a slice thickness of 1 mm. All models were used to plan the resection and to identify the anatomic landmarks during the operation. With the aid of these full-scale spinal models, all surgical procedures were performed exactly according to the preoperative plan. A 16-year-old girl with congenital scoliosis with a Cobb angle greater than 90° received staged surgery, including vertebral column resection, correction, and posteriolateral spinal fusion. The other patient was a 3-year-old boy with 80° of Gibbus spine deformity. By means of an anteriolateral approach after thoracotomy, the paraspinal abscess debridement, vertebral column resection, and vertical expandable prosthetic titanium rib application were performed. No postoperative complications such as spinal cord, nerve root, or major vascular injuries were found. The 3D RP models are really helpful in providing direct visual and tactile feedback, improving preoperative planning, identifying the important anatomic landmarks during the surgery, and communicating with patients. If the RP technique can be improved in the future, it is likely to become more acceptable and practical.

Reducing surgical site infections in hepatopancreatobiliary surgery

ObjectivesPatients undergoing complex hepatopancreatobiliary (HPB) operations are at high risk for surgical site infection (SSI). Factors such as biliary obstruction, operative time and pancreatic or biliary fistulae contribute to the high SSI rate. The purpose of this study was to analyse whether a multifactorial approach would reduce the incidence and cost of SSI after HPB surgery. MethodsFrom January 2007 to December 2009, 895 complex HPB operations were monitored for SSI through the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP). In 2008, surgeon‐specific SSI rates were provided to HPB surgeons, and guidelines for the management of perioperative factors were established. Observed SSI rates were monitored before and after these interventions. Hospital cost data were analysed and cost savings were calculated. ResultsObserved SSI for hepatic, pancreatic and complex biliary operations decreased by 9.6% over a 2‐year period (P < 0.03). The excess cost per SSI was US$11 462 and was driven by increased length of stay and hospital readmission for infection. Surgeons rated surgeon‐specific feedback on SSI rate as the most important factor in improvement. ConclusionsHigh SSI rates following complex HPB operations can be improved by a multifactorial approach that features process improvements, individual surgeon feedback and reduced variation in patient management.

Evaluation of a minimally invasive renal cooling device using heat transfer analysis and an in vivo porcine model

Partial nephrectomy is the gold standard treatment for renal cell carcinoma. This procedure requires temporary occlusion of the renal artery, which can cause irreversible damage due to warm ischemia after 30min. Open surgical procedures use crushed ice to induce a mild hypothermia of 20°C in the kidney, which can increase allowable ischemia time up to 2.5h. The Kidney Cooler device was developed previously by the authors to achieve renal cooling using a minimally invasive approach. In the present study an analytical model of kidney cooling in situ was developed using heat transfer equations to determine the effect of kidney thickness on cooling time. In vivo porcine testing was conducted to evaluate the cooling performance of this device and to identify opportunities for improved surgical handling. Renal temperature was measured continuously at 6 points using probes placed orthogonally to each other within the kidney. Results showed that the device can cool the core of the kidney to 20°C in 10–20min. Design enhancements were made based on surgeon feedback; it was determined that the addition of an insulating air layer below the device increased difficulty of positioning the device around the kidney and did not significantly enhance cooling performance. The Kidney Cooler has been shown to effectively induce mild renal hypothermia of 20°C in an in vivo porcine model.

A decade’s experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000–2009

The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade. This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome. Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes. Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.

A review of intraoperative monitoring for spinal surgery.

Background:Intraoperative neurophysiologic monitoring (IONM) is a technique that is helpful for assessing the nervous system during spine surgery.Methods:This is a review of the field describing the basic mechanisms behind the techniques of IONM. These include the most often utilized trancranial motor evoked potentials (Tc-MEPs), somatosensory evoked potentials (SSEPs), and stimulated and spontaneous EMG activity. It also describes some of the issues regarding practices and qualifications of practitioners.Results:Although the anatomic pathways responsible for the Tc-MEP and SSEP are well known and these clinical techniques have a high sensitivity and specificity, there is little published data showing that monitoring actually leads to improved patient outcomes. It is evident that IONM has high utility when the risk of injury is high, but may be only marginally helpful when the risk of injury is very low. The monitoring team must be well trained, be able to provide the surgeon feedback in real time, and coordinate activities with those of the surgical and anesthesia teams.Conclusions:Although IONM is a valuable technique that provides sensitive and specific indications of neurologic injury, it does have limitations that must be understood. Maintaining a high quality of practice with appropriately trained personnel is critical.

Validation of a novel laparoscopic adjustable gastric band simulator

Morbid obesity accounts for more than 90,000 deaths per year in the United States. Laparoscopic adjustable gastric banding (LAGB) is the second most common weight loss procedure performed in the US and the most common in Europe and Australia. Simulation in surgical training is a rapidly advancing field that has been adopted by many to prepare surgeons for surgical techniques and procedures. The aim of our study was to determine face, construct, and content validity for a novel virtual reality laparoscopic adjustable gastric band simulator. Twenty-eight subjects were categorized into two groups (expert and novice), determined by their skill level in laparoscopic surgery. Experts consisted of subjects who had at least 4 years of laparoscopic training and operative experience. Novices consisted of subjects with medical training but with less than 4 years of laparoscopic training. The subjects used the virtual reality laparoscopic adjustable band surgery simulator. They were automatically scored according to various tasks. The subjects then completed a questionnaire to evaluate face and content validity. On a 5-point Likert scale (1 = lowest score, 5 = highest score), the mean score for visual realism was 4.00 ± 0.67 and the mean score for realism of the interface and tool movements was 4.07 ± 0.77 (face validity). There were significant differences in the performances of the two subject groups (expert and novice) based on total scores (p < 0.001) (construct validity). Mean score for utility of the simulator, as addressed by the expert group, was 4.50 ± 0.71 (content validity). We created a virtual reality laparoscopic adjustable gastric band simulator. Our initial results demonstrate excellent face, construct, and content validity findings. To our knowledge, this is the first virtual reality simulator with haptic feedback for training residents and surgeons in the laparoscopic adjustable gastric banding procedure.

The Learning Curve for Surgical Margins After Open Radical Prostatectomy: Implications for Margin Status as an Oncological End Point

Surgical margin status is commonly used as an end point for surgical learning. We examined the surgical margin learning curve and investigated whether surgical margins are a good marker for oncological outcome. The study cohort included 7,765 patients with prostate cancer treated with radical prostatectomy by 1 of 72 surgeons at a total of 4 major American academic medical centers. We calculated the learning curve for surgical margins and a concordance probability between the surgeon rates of positive surgical margins and 5-year biochemical recurrence. A positive surgical margin was identified in 2,059 patients (27%). On multivariate analysis surgeon experience was strongly associated with surgical margin status (p = 0.017). The probability of a positive surgical margin was 40% for a surgeon with 10 prior cases, which decreased to 25% for a surgeon with 250 (absolute difference 15%, 95% CI 11 to 18). Learning curves differed dramatically among surgeons. For surgeon pairs the surgeon with the superior positive surgical margin rate also had the better biochemical recurrence rate only 58% of the time. We noted a learning curve for surgical margins after open radical prostatectomy. The poor concordance between surgeon margin and recurrence rates suggests that while margins clearly matter and efforts should be made to decrease positive margin rates, surgical margin status is not a strong surrogate for cancer control. These results have implications for using the margin rate to evaluate changes in surgical technique and as surgeon feedback.

Orthopedic management of spina bifida

The management of orthopedic problems in spina bifida has seen a dramatic change over the past 10 years. The negative effects of spasticity, poor balance, and the tethered cord syndrome on ambulatory function are better appreciated. There is less emphasis on the hip radiograph and more emphasis on the function of the knee and the prevention of knee pain. The importance of the hip abductor muscle and its influence on gait and knee function has been realized. Important developments in the treatment of spinal deformity include the use of pedicle screws which allow better correction. The role of anterior-only spinal surgery has been defined, which allows motion at the lumbo-sacral junction and has a lower postoperative infection rate than posterior surgery. Functional outcome assessments provide better feedback for surgeons and families in regards to which patients may benefit most from surgery. Overall, the past 10 years has seen the increased use of functional outcome measures such as Motion Analysis, oxygen consumption, and patient-based outcome assessments rather than traditional radiographic measures (e.g., hip dislocation or subluxation). This progress has resulted in a better understanding of spina bifida and, more importantly, improved outcomes for our patients. Additional research is likely to further enhance outcomes by establishing additional evidence-based interventions.

Workshop: summary of discussions and conclusions

1. Local application of collagen-gentamicin for prevention of sternal wound infection (SWI) is a fairly new concept. Is there reason to present recommendations or precautions regarding its use after summarizing the documentation and clinical experience so far? 2. An objective and reliable registration of all postoperative wound infections constitutes the basis for further improvements and allows the comparison of SWI rates over time and between centres. Is it possible to achieve recommendations for uniform follow-up of postoperative surgical site infections (SSI) after cardiac surgery among centres in the Nordic countries? 3. National registries exist for a number of diagnoses and conditions in Sweden. Is the time ripe for a National Medistinitis Registry? What should be the aim and design of such a registry?

The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room

The study was carried out to demonstrate the impact of assessment and constructive feedback on improvement of laparoscopic performance in the operating room (OR). Sixteen surgical trainees performed a laparoscopic cholecystectomy in the OR. The participants were then divided into two groups. The procedure performed by group 1 was assessed by an experienced surgeon, and detailed and constructive feedback was provided to each trainee. Group 2 received no feedback. Subsequently, all subjects performed a new laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotapes and assessed by two independent and blinded observers using a validated scoring system. Error and economy of movements score assessed during the laparoscopic procedures in the OR. No differences in baseline assessments were found between the two groups (t-test, p > 0.5). Surgeons, who received feedback (group 1) made significantly greater improvement in their time to complete the following procedure (independent sample t-test, p = 0.022), error (t-test, p = 0.003) and economy of movement scores (t-test, p < 0.001). Surgeons who received constructive feedback made significantly greater improvement in their performance in the OR compared with those in the control group. The study provides objective evidence that assessment is beneficial for surgical training and should be implemented in the educational programmes in the future.

Unilateral Stereotactic Posteroventral Globus Pallidus Internus Pallidotomy for Parkinson's Disease: Surgical Techniques and 2-Year Follow-Up

With the advent of levodopa (L-dopa) and the recognition of its striking effect on Parkinson's disease (PD), virtually all surgical procedures for PD ceased from the mid 1960s. However, there has been a resurgence of pallidotomy and other stereotactic procedures in the last two decades as physicians realized that most PD patients eventually face medical failure after long-term treatment with L-dopa. Nine PD patients, three men and six women, with an average age of 62 years and disease duration of 13 years underwent unilateral globus pallidus internus (GPi) pallidotomy contralateral to the side with marked akinetic symptoms and drug-induced dyskinesia. All patients were evaluated using the Unified Parkinson's disease Rating Scale (UPDRS) after drug withdrawal and while taking their optimal medical regimen, preoperatively and 6, 12, and 24 months after surgery. There was significant improvement in activities of daily living and motor subscores as well as total UPDRS score in the "off" state at the 2-year follow-up, which mainly resulted from improvement in contralateral bradykinesia and rigidity. Significant improvements in contralateral akinetic symptoms and drug-induced dyskinesia were also observed in the "on" state and were sustained for at least 2 years. Ipsilateral and axial symptoms were not altered by unilateral GPi pallidotomy. The complications of surgery were generally well tolerated. One patient had a small postoperative asymptomatic hemorrhage identified by routine follow-up magnetic resonance imaging. Another two patients developed temporary sexual disinhibition and auditory hallucination, respectively, which resolved spontaneously 2 weeks after surgery. The effect of pallidotomy for alleviation of akinetic parkinsonism is modest but significant, and continues to be effective for at least 2 years. Further analytical studies, especially the correlation of clinical effects and lesion locations, are important not only to provide direct feedback for surgeons to examine the technical accuracy and but also to facilitate understanding of the pathophysiology of PD.