C.6 Action-Related Fixation in Microsuturing, a New Gaze Behavior Metric to Differentiate the Level of Expertise

Background: Gaze behavior differences between expert and novice surgeons have been established in previous studies mainly from the general surgery field.Limited information is available about surgeon’s visual attention during microsurgery procedures where surgical microscope is used. Methods: 4 experts and 3 novices performed 37 independent sutures under the surgical microscope.Eye movements of surgeons and scene video of the surgical performance were recorded.Total suturing time and subtask times were compared between level of expertise.We defined three discrete surgical actions and examined eye gaze (fixation) directly related to each of these actions.Fixation duration (measured by total,pre-action,and post-action duration) were compared between expert and novice, over 3 subtasks (piercing, exiting and cutting) and between pre- and post-action phases. Results: Expert surgeons completed the suture with shorter total time than novices.On average,expert displayed longer fixation time than novice.Experts also maintained their visual engagement constantly over the 3 level of subtask in comparison to novices who required a longer fixation time for the challenging subtask (piercing).Experts use longer pre- than post-action fixation, and this pattern is distributed over all three subtasks.This gaze engagement strategy was not shown in novices. Conclusions: The action-related fixation can be used to evaluate microsurgeons’ level of expertise and in surgical education for gaze training.

Management of small perforated corneal ulcers: Training model in mammalian eye to enhance surgical skills of residents

Purpose: To demonstrate a training technique on the mammalian eye for optimum Cyanoacrylate Tissue adhesive application in cases of perforated corneal ulcers. Methods: A full-thickness defect simulating a perforation was created on the goat’s eye cornea to teach the technique of cyanoacrylate glue application in cases of corneal perforations to novice surgeons. Results: This training model on the mammalian eye was tested by 10 residents at our centre. All the 10 candidates involved in our series were newly joined Cornea fellows with proficient skill in cataract surgeries and minor ophthalmic procedures such as suture removal, chalazion excision, pterygium removal and administration of an intravitreal injection. None of the candidates had prior experience of corneal surgeries. Each resident made an average of 4.4 attempts to seal the corneal defect, obtain a regular corneal surface and form the anterior chamber. Conclusion: This training model helps in mastering one of the skills of corneal surgeries.

Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy

Background The purpose of this study was to compare the degree of accuracy of coronal alignment correction with use of the “alignment adjustment under valgus stress technique” between expert and novice surgeons during medial opening-wedge high tibial osteotomy (MOWHTO). Methods Forty-eight patients who underwent MOWHTO performed by an expert surgeon (expert group) and 29 by a novice surgeon (novice group) were enrolled in analysis. During surgery, lower-extremity alignment was corrected using the “alignment adjustment under valgus stress technique”. Normocorrection was defined as a weight-bearing line ratio between 55 and 70% and the correction accuracy was compared between expert and novice groups using the ratio of normocorrection to outliers. The clinical outcomes were also compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year after surgery. Results The undercorrection rate was 14.6% in the expert group and 13.8% in the novice group, while the overcorrection rate was 2.1% in the expert group and 3.4% in the novice group. In the ratio of normocorrection to outliers, no difference was found between the two groups at the one-year follow-up visit (83.3% in the expert group vs. 82.8% in the novice group; p > 0.05). Also, no significant differences were seen in WOMAC subscores immediately preoperatively and at 1 year after surgery (all p > 0.05). Conclusion Adhering to the “alignment adjustment under valgus stress technique” protocol enabled novice surgeons to achieve similar surgical accuracy as that of an expert surgeon in coronal alignment during MOWHTO. Level of evidence Level III.

Which Factors Affect the Stress of Intraoperative Orthopedic Surgeons by Using Electroencephalography Signals and Heart Rate Variability?

Can we recognize intraoperative real-time stress of orthopedic surgeons and which factors affect the stress of intraoperative orthopedic surgeons with EEG and HRV? From June 2018 to November 2018, 265 consecutive records of intraoperative stress measures for orthopedic surgeons were compared. Intraoperative EEG waves and HRV, comprising beats per minute (BPM) and low frequency (LF)/high frequency (HF) ratio were gathered for stress-associated parameters. Differences in stress parameters according to the experience of surgeons, intraoperative blood loss, and operation time depending on whether or not a tourniquet were investigated. Stress-associated EEG signals including beta 3 waves were significantly higher compared to EEG at rest for novice surgeons as the procedure progressed. Among senior surgeons, the LF/HF ratio reflecting the physical demands of stress was higher than that of novice surgeons at all stages. In surgeries including tourniquets, operation time was positively correlated with stress parameters including beta 1, beta 2, beta 3 waves and BPM. In non-tourniquet orthopedic surgeries, intraoperative blood loss was positively correlated with beta 1, beta 2, and beta 3 waves. Among orthopedic surgeons, those with less experience demonstrated relatively higher levels of stress during surgery. Prolonged operation time or excessive intraoperative blood loss appear to be contributing factors that increase stress.

Robotic Applications for Benign Gynecologic Procedures

Introduction: Robotic systems provide a platform for surgeons to expand their capabilities, allowing them to perform complex procedures safely and efficiently. Within the field of benign gynecology, this has become an increasingly popular option since receiving Food and Drug Administration (FDA) approval in 2005. However, the appropriate indications for robotic versus laparoscopic surgery continue to be debated. Materials and Methods: Literature was reviewed to provide a comprehensive, evidence-based evaluation of the advantages and pitfalls of robotic surgery, the applications of robotic surgery for benign gynecologic procedures in comparison to conventional laparoscopy, and the role of robotic surgery as an educational tool. Results: Robotic surgery has favorable outcomes for surgeons in the areas of ergonomics, dexterity, and fatigue. Cost comparisons are widely varied and elaborate. Most patient outcomes are comparable between robotic and laparoscopic hysterectomies and endometriosis resections. In patients with a body mass index >30mg/m2 and uteri >750mg, hysterectomy outcomes are improved when surgery is done robotically. The use of the robotic system may be beneficial for patients undergoing myomectomy. Robotic surgery confers advantages for trainees and novice surgeons. There is no consensus on a standardized curriculum for robotic training or credentialing process for experienced surgeons. Conclusion: Robotic surgery has distinct features that make it a valuable tool for gynecologic surgeons. There are no clear indications regarding when a robotic route should be chosen but could be considered when above average complexity is anticipated and when training new surgeons.

Effectiveness of simulation-based training for manual small incision cataract surgery among novice surgeons: a randomized controlled trial

This study was designed to determine the effect of a novel simulation-based training curriculum for scleral tunnel construction in manual small incision cataract surgery (MSICS) compared with traditional training. In this multicenter, investigator-masked, randomized clinical trial, resident surgeons within 3 months of matriculation with minimal or no prior experience with MSICS were assigned either to simulation-based training, the Experimental Group (EG), or to conventional training, the Control Group (CG). EG residents were trained to perform scleral tunnel construction using a simulation-based curriculum (HelpMeSee Eye Surgery Simulator), while residents in the CG followed institution-specific curriculum before progressing to live surgery. Surgical videos of the first 20 attempts at tunnel construction were reviewed by masked video raters. The primary outcome was the total number of any of 9 pre-specified errors. On average, the total number of errors was 9.25 (95% CI 0–18.95) in the EG and 17.56 (95% CI 6.63–28.49) in the CG (P = 0.05); the number of major errors was 4.86 (95% CI 0.13–9.59) in the EG and 10.09 (95% CI 4.76–15.41) in the CG (P = 0.02); and the number of minor errors was 4.39 (95% CI 0–9.75) in the EG and 7.47 (95% CI 1.43–13.51) in the CG (P = 0.16). These results support that novice surgeons trained using the novel simulation-based curriculum performed fewer errors in their first 20 attempts at tunnel construction compared to those trained with a conventional curriculum.

Inverse centripetal dissection: A rescue technique for mis-dissected lenticule during SMILE

Management of mis-dissected lenticule during Small-incision lenticule extraction (SMILE) is technically challenging and might be experienced more by novice surgeons especially in eyes with low refractive errors and thin lenticules. Presently, we describe a rescue method of inverse centripetal dissection (ICD) to manage mis-dissected lenticules. In this technique, after inadvertent dissection of posterior plane prior to anterior plane, the double-ended SMILE dissector is rotated along its shaft axis clockwise from the left upper margin of the mis-dissected lenticule to form an inversely folded lenticule which is then subsequently dissected centripetally till midline. This is then extracted by performing lenticulorrhexis with a pair of microforceps. We performed this technique in 10 eyes of 10 patients and the lenticule extraction was accomplished successfully in all eyes. At six months follow-up, the uncorrected visual acuity was 20/20 with a clear interface in all eyes. The ICD approach might serve as a useful rescue technique for managing mis-dissected lenticules.

Surgeons’ Preference for Off-Pump or On-Pump Coronary Artery Bypass Grafting Surgery

Background: Surgeon’s preference is an important factor in clinical strategy for off-pump (OPCAB) or on-pump (ONCAB) coronary artery bypass graft (CABG) surgery. This study analyzed surgeons’ understanding of and propensity for both techniques. Methods: A survey was performed by self-reported questionnaire. Two sections were included: Q1 questionnaire investigated each surgeon’s opinion on the indications of OPCAB and ONCAB; and Q2 questionnaire investigated each surgeon’s choice of OPCAB or ONCAB in different clinical situations. Results: The questionnaires were sent to 169 surgeons. In Q1, 71.2% of surgeons indicated that the degree of overlap between the indications of OPCAB and ONCAB is >70%; 55.1% believed that OPCAB had a wider scope of indications than ONCAB, and 35.3% believed that ONCAB had a wider scope of indications than OPCAB. In Q2, >70% of surgeons who responded chose OPCAB for patients with the following characteristics: high risk of stroke, renal dysfunction, pulmonary dysfunction, malignancy, clotting and coagulation disorders, or age ≥80 years. More than 57.5% of surgeons chose ONCAB for patients with poor target vessels or ventricular enlargement and dysfunction. For novice surgeons, 87.5% of surgeons chose ONCAB. Conclusion: Most surgeons surveyed agreed that OPCAB and ONCAB are suitable for most patients; however, surgeons’ preference for ONCAB or OPCAB varied. Surgeons are more willing to choose ONCAB in the presence of complicated heart conditions and OPCAB in the presence of serious concomitant diseases.

845 Flattening the Learning Curve: The Evaluation of Extended Laparoscopic Simulation Training for Novice Surgeons

Introduction Associated with faster postoperative recovery, reduced length of hospital stays and scarring; laparoscopy has become the favoured approach for many surgical procedures across a range of specialties. However, due to its challenging learning curve, it has also been associated with increased theatre time and higher complication rates. Method A prospective, observational study with box trainers was carried out by novice medical students and trainees to evaluate the efficacy of long duration courses on skill acquisition. The novice group undertook a 5-week curriculum composed of lectures, demonstrations and spaced timed-assessments involving 3 tasks: hoop placement, stacking of sugar cubes and surgical cutting. Results Time taken for novice participants to complete a task individually and collectively improved markedly from the first to the third attempt, with an overall 44% reduction in time observed over the 5-weeks. We invited back 6 novice participants and 6 core surgical trainees after 4-weeks to complete the same tests. There was a further 18% time improvement in the novice group, with 44% faster task completion. Conclusions Given the success of this study and other simulation courses reported in the literature, we recommend more courses adopt a spaced-out approach; and a simulation curriculum for surgical trainees to cultivate greater skill acquisition.