Triad of rubric assessment, constructive feedback and video recorded surgeries key assessment for competent ophthalmic surgeon

Ophthalmic surgery involves very precise surgical skill, which is difficult to teach and even more cumbersome in assessment of resident’s surgical skill. Hence it’s a need of time to adopt newer tool for transferring as well as assessing surgical skill. With this concept in mind International Council of Ophthalmology (ICO) has developed various tools for assessing surgical skills. If we use this tool not only as learning tool but also to give constructive feedback on the surgical skills of resident doctors it will help in creating a competent ophthalmic surgeon and eventually help society in general. 1To develop more standardized surgical training; 2. To assess efficacy and feasibility of new tool in improving surgical skills of Post Graduate(PG) student; 3. To know the effect of constructive feedback on surgical performance. Small incision cataract surgery training is done by Rubric designed by ICO- OSCAR. The same tool was used to assess video recorded cataract surgery of residents by different faculties and assess their surgical skill. The assessor simply circled the observed performance description at each step of the procedure. The ICO-OSCAR score was completed. At the end of the case assessor immediately discussed operated case with student to provide timely, structured, specific performance feedback. Oscar score was recorded and analysed with inter rater agreement. OSCAR TOOL has very good inter rater agreement i.e.(0.96). Analysis of student & Observer feedback infers that OSCAR Tool is best tool for learning as well as assessment tool and is easy to use. Recorded surgeries & constructive feedback from assessor helped Post Graduate students to improve surgically. This resulted in best outcome for patient in terms of good visual acuity post operatively. The formative assessment of surgical skills becomes an integral part of our formal residency, training framework, it would be in the interest of our trainees and trainers that we should adopt the OSCAR tools to train and assess. These tools can add immense value to our residency as well fellowship surgical training and possibly help create a generation of competent trainee.Formative Assessment and constructive feedback in surgical training will improve the competency of new ophthalmic surgeons.Structured surgical training will be relatively easy to observe and perform, as trainee learns what is required to be competent.This will ultimately improve the overall quality of patient care.

Validation of a novel virtual reality simulation system with the focus on training for surgical dissection during laparoscopic sigmoid colectomy

Background Mastery of technical skills is one of the fundamental goals of surgical training for novices. Meanwhile, performing laparoscopic procedures requires exceptional surgical skills compared to open surgery. However, it is often difficult for trainees to learn through observation and practice only. Virtual reality (VR)-based surgical simulation is expanding and rapidly advancing. A major obstacle for laparoscopic trainees is the difficulty of well-performed dissection. Therefore, we developed a new VR simulation system, Lap-PASS LP-100, which focuses on training to create proper tension on the tissue in laparoscopic sigmoid colectomy dissection. This study aimed to validate this new VR simulation system. Methods A total of 50 participants were asked to perform medial dissection of the meso-sigmoid colon on the VR simulator. Forty-four surgeons and six non-medical professionals working in the National Cancer Center Hospital East, Japan, were enrolled in this study. The surgeons were: laparoscopic surgery experts with > 100 laparoscopic surgeries (LS), 21 were novices with experience < 100 LS, and five without previous experience in LS. The participants’ surgical performance was evaluated by three blinded raters using Global Operative Assessment of Laparoscopic Skills (GOALS). Results There were significant differences (P-values < 0.044) in all GOALS items between the non-medical professionals and surgeons. The experts were significantly superior to the novices in one item of GOALS: efficiency ([4(4–5) vs. 4(3–4)], with a 95% confidence interval, p = 0.042). However, both bimanual dexterity and total score in the experts were not statistically different but tended to be higher than in the novices. Conclusions Our study demonstrated a full validation of our new system. This could detect the surgeons' ability to perform surgical dissection and suggest that this VR simulator could be an effective training tool. This surgical VR simulator might have tremendous potential to enhance training for surgeons.

P-OGC53 Dashboarding for real-time analysis of oesophagogastric outcomes data

Background The typical paradigm for surgical service evaluation is intermittent audit based on perceived clinical need and mandated requirements. A better model would be monitoring patient outcomes automatically in real-time, with up-to-date cumulative frequencies of key surgical performance indicators such as surgical quality and morbidity, as changes in performance could be detected and reacted to at an earlier stage. This study aimed to develop a dashboarding technology to support real-time visualisation of prospectively maintained oesophagogastric cancer surgery data. Methods CODA is a bespoke databank (implemented in MS SQL Server, with HTML, C# and JavaScript) for oesophagogastric cancer care at our centre. We built on a custom dashboard interface for displaying this information in real-time, using Shiny for R and Tableau. We identified the key performance indicators (KPIs) to monitor in the dashboard, and defined benchmarks based on accepted standards, or our prevailing performance (based on 448 consecutive patients who underwent oesophagectomy between 2015 – 2020). The domains selected were surgical quality, length of stay, early mortality, and priority complications. Complications were defined according to the Esophagectomy Complications Consensus Group. Results For surgical quality, our benchmarks based on prevailing performance were (i) &gt;90% &gt;15 lymph node yield (ii) &lt;2-5% longitudinal R1 (iii) &lt;20-30% CRM R1. For length of stay, our benchmarks were (i) &gt;33% meeting 8 day discharge target (ii) &lt;15% missing target discharge without a medical complication (iii) &lt;20% staying longer than two weeks. For 30 & 90 day mortality, our benchmarks were 2% and 4% respectively. For complications, two sets were identified: (i) common complications (occurring at &gt; 2 / year, monitored 2-yearly) (ii) impactful complications (&gt;1 / year, &gt;1 week median additional stay, monitored 5-yearly) Conclusions The CODA dashboard provides real-time appraisal of oesophagogastric cancer surgery practice, highlighting changes in performance and providing opportunity for early intervention. The platform can be used for personal, departmental or inter-institutional service evaluation. The KPIs will be extended to oesophagogastric cancer survival as the test set matures. The interface and wider benefits of CODA implementation are presented, together with the dissemination plan for use in other oesophagogastric centres.

Performance with robotic surgery versus 3D- and 2D­laparoscopy during pancreatic and biliary anastomoses in a biotissue model: pooled analysis of two randomized trials

Background Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). Methods Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017–July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12–60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. Results A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D­laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0–2) versus 6 years (4–12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D­laparoscopy, respectively, which remained in the sensitivity analysis. Conclusion In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.

Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Cerebral abscess secondary to embolization of arteriovenous malformation: A case report and literature review

Background: Infectious complications of the central nervous system secondary to endovascular procedures have rarely been reported. However, the number of complications has grown exponentially owing to the popularization of these procedures. The success rate of these procedures varies with the pathology, the patient, and surgical performance. Although brain abscesses have been extensively reported, their presence after endovascular procedures has not been described in detail in the literature. We present a case of brain abscess induced by embolization of an arteriovenous malformation (AVM), discuss the main indications, techniques, procedural complications, and review the associated literature. Case Description: A 13-year-old boy presented to us with a history of hemorrhagic stroke secondary to a cerebral AVM rupture. He underwent incomplete AVM resection (2014), with subsequent incomplete embolization (2017), and permanence of the endovenous catheter as a procedural complication. Physical examination revealed purulent exudate through the cervical surgical wound. We performed cervicotomy to remove the catheter but had no success in removing the intracranial material segment. The patient was subsequently diagnosed with a brain abscess (2018) and treated with antibiotics. Our team performed resection of the residual AVM, abscess, and the catheter-associated with the region. Conclusion: The patient showed significant clinical improvement after surgical resection of the malformation. No residual lesions were observed in the imaging examinations. Further, we reviewed the literature to find other cases of similar complications and their association with the endovascular procedure. We did not find complications in patients younger than the one presented in this case. Factors such as incomplete embolisation increase the risk of unfavourable outcomes.

Gender benefit in laparoscopic surgical performance using a 3D-display system: data from a randomized cross-over trial

Background The use of 3D technique compared to high-resolution 2D-4K-display technique has been shown to optimize spatial orientation and surgical performance in laparoscopic surgery. Since women make up an increasing amount of medical students and surgeons, this study was designed to investigate whether one gender has a greater benefit from using a 3D compared to a 4K-display system. Methods In a randomized cross-over trial, the surgical performance of male and female medical students (MS), non-board certified surgeons (NBCS), and board certified surgeons (BCS) was compared using 3D- vs. 4K-display technique at a minimally invasive training parkour with multiple surgical tasks and repetitions. Results 128 participants (56 women, 72 men) were included. Overall parkour time in seconds was 3D vs. 4K for all women 770.7 ± 31.9 vs. 1068.1 ± 50.0 (p < 0.001) and all men 664.5 ± 19.9 vs. 889.7 ± 31.2 (p < 0.001). Regarding overall mistakes, participants tend to commit less mistakes while using the 3D-vision system, showing 10.2 ± 1.1 vs. 13.3 ± 1.3 (p = 0.005) for all women and 9.6 ± 0.7 vs. 12.2 ± 1.0 (p = 0.001) for all men. The benefit of using a 3D system, measured by the difference in seconds, was for women 297.3 ± 41.8 (27.84%) vs. 225.2 ± 23.3 (25.31%) for men (p = 0.005). This can be confirmed in the MS group with 327.6 ± 65.5 (35.82%) vs. 249.8 ± 33.7 (32.12%), p = 0.041 and in the NBCS group 359 ± 52.4 (28.25%) vs. 198.2 ± 54.2 (18.62%), p = 0.003. There was no significant difference in the BCS group. Conclusion 3D laparoscopic display technique optimizes surgical performance compared to the 2D-4K technique for both women and men. The greatest 3D benefit was found for women with less surgical experience. As a possible result of surgical education, this gender specific difference disappears with higher grade of experience. Using a 3D-vision system could facilitate surgical apprenticeship, especially for women.

SIM: The Surgery Imagery Mindset and Preparing for Surgery

Discussed under various terms such as mental skills, mental rehearsal, cognitive training, and non-technical skills, psychological performance skills are gaining greater acceptance for their contributions to excellence in surgical performance. Mental imagery, specifically performance-enhancing mental imagery for surgeons, has received the greatest attention in the surgical literature. As part of the surgeon’s imagery mindset (SIM), this form of mental rehearsal contributes to optimal surgical performance for both developing and practicing surgeons. We discuss the nature of SIM and describe 5 basic guidelines for maximizing the application of performance-enhancing mental imagery in surgical contexts.

A Neurotechnological Aid For Semi-Autonomous Suction In Robotic-Assisted Surgery

Adoption of Robotic-Assisted Surgery has steadily increased as it improves the surgeon’s dexterity and visualization. Despite these advantages, the success of a robotic procedure is highly dependent on the availability of a proficient surgical assistant that can collaborate with the surgeon. With the introduction of novel medical devices, the surgeon has taken over some of the surgical assistant’s tasks to increase their independence. This, however, has also resulted in surgeons experiencing higher levels of cognitive demands that can lead to reduced performance. In this work, we proposed a neurotechnology-based semi-autonomous assistant to release the main surgeon of the additional cognitive demands of a critical support task: blood suction. To create a more synergistic collaboration between the surgeon and the robotic assistant, a real-time cognitive workload assessment system based on EEG signals and eye-tracking was introduced. A computational experiment demonstrates that cognitive workload can be effectively detected with an 80% accuracy. Then, we show how the surgical performance can be improved by using the neurotechnological autonomous assistant as a close feedback loop to prevent states of high cognitive demands. Our findings highlight the potential of utilizing real-time cognitive workload assessments to improve the collaboration between an autonomous algorithm and the surgeon.

Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

Introduction Flow disruptions (FD) in the operating room (OR) have been found to adversely affect the levels of stress and cognitive workload of the surgical team. It has been concluded that frequent disruptions also lead to impaired technical performance and subsequently pose a risk to patient safety. However, respective studies are scarce. We therefore aimed to determine if surgical performance failures increase after disruptive events during a complete surgical intervention. Methods We set up a mixed-reality-based OR simulation study within a full-team scenario. Eleven orthopaedic surgeons performed a vertebroplasty procedure from incision to closure. Simulations were audio- and videotaped and key surgical instrument movements were automatically tracked to determine performance failures, i.e. injury of critical tissue. Flow disruptions were identified through retrospective video observation and evaluated according to duration, severity, source, and initiation. We applied a multilevel binary logistic regression model to determine the relationship between FDs and technical performance failures. For this purpose, we compared FDs in one-minute intervals before performance failures with intervals without subsequent performance failures. Results Average simulation duration was 30:02 min (SD = 10:48 min). In 11 simulated cases, 114 flow disruption events were observed with a mean hourly rate of 20.4 (SD = 5.6) and substantial variation across FD sources. Overall, 53 performance failures were recorded. We observed no relationship between FDs and likelihood of immediate performance failures: Adjusted odds ratio = 1.03 (95% CI 0.46–2.30). Likewise, no evidence could be found for different source types of FDs. Conclusion Our study advances previous methodological approaches through the utilisation of a mixed-reality simulation environment, automated surgical performance assessments, and expert-rated observations of FD events. Our data do not support the common assumption that FDs adversely affect technical performance. Yet, future studies should focus on the determining factors, mechanisms, and dynamics underlying our findings.