618 Management of Rectal Cancer in England And Wales. Is the Rate of Abdominoperineal Excision of Rectum Associated with The Pre-Operative Radiotherapy Rates?

Aim Rectal cancer treatment has improved over the years, but variations in practice remain. Abdominoperineal resection (APER) is associated with significant morbidity and pre-operative radiotherapy (RT) is only recommended for advanced rectal cancer. As such, APER and RT should be reserved for patients with an appropriate clinical need. The aim of the study is to evaluate the association between the rates of APER and RT, and whether any other factors are associated. Method Data on rectal cancer cases was extracted from National Bowel Cancer Audit 2019. Primary outcomes were: APER rate, RT rate. Pearson’s correlation coefficient was calculated. The means for APER and pre-operative radiotherapy were plotted on a four-quadrant matrix. The differences were analysed using Mann-Whitney U and Student T-test. Results 3,764 patients were included. A mean of 25% (95%CI: 10.3-14.9%) underwent APER and an average of 34% (95%CI: 30.5-36.8%) received RT. There was a weak positive correlation between rates of APER and RT (r = 0.356, p < 0.001). 43 (37%) trusts had proportions of both APER and RT below the overall mean, whilst 30 (26%) had both proportions above. No significant differences were found when comparing other variables between the high to low-rate trusts (p > 0.05). Conclusions There is a weak positive correlation between the proportion of rectal cancer patients undergoing APER and the proportion receiving RT in trusts across England and Wales. It is unknown whether this finding has a clinical significance and further analysis on trust/surgeon performance and patient demographics is needed, allowing for prevention strategies to be implemented.

A systematic review of virtual reality for the assessment of technical skills in neurosurgery

OBJECTIVE Virtual reality (VR) and augmented reality (AR) systems are increasingly available to neurosurgeons. These systems may provide opportunities for technical rehearsal and assessments of surgeon performance. The assessment of neurosurgeon skill in VR and AR environments and the validity of VR and AR feedback has not been systematically reviewed. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted through MEDLINE and PubMed. Studies published in English between January 1990 and February 2021 describing the use of VR or AR to quantify surgical technical performance of neurosurgeons without the use of human raters were included. The types and categories of automated performance metrics (APMs) from each of these studies were recorded. RESULTS Thirty-three VR studies were included in the review; no AR studies met inclusion criteria. VR APMs were categorized as either distance to target, force, kinematics, time, blood loss, or volume of resection. Distance and time were the most well-studied APM domains, although all domains were effective at differentiating surgeon experience levels. Distance was successfully used to track improvements with practice. Examining volume of resection demonstrated that attending surgeons removed less simulated tumor but preserved more normal tissue than trainees. More recently, APMs have been used in machine learning algorithms to predict level of training with a high degree of accuracy. Key limitations to enhanced-reality systems include limited AR usage for automated surgical assessment and lack of external and longitudinal validation of VR systems. CONCLUSIONS VR has been used to assess surgeon performance across a wide spectrum of domains. The VR environment can be used to quantify surgeon performance, assess surgeon proficiency, and track training progression. AR systems have not yet been used to provide metrics for surgeon performance assessment despite potential for intraoperative integration. VR-based APMs may be especially useful for metrics that are difficult to assess intraoperatively, including blood loss and extent of resection.

Association between Functional Brain Network Metrics and Surgeon Performance and Distraction in the Operating Room

Objective: The aim of this work was to examine (electroencephalogram) EEG features that represent dynamic changes in the functional brain network of a surgical trainee and whether these features can be used to evaluate a robot assisted surgeon’s (RAS) performance and distraction level in the operating room. Materials and Methods: Electroencephalogram (EEG) data were collected from three robotic surgeons in an operating room (OR) via a 128-channel EEG headset with a frequency of 500 samples/second. Signal processing and network neuroscience algorithms were applied to the data to extract EEG features. The SURG-TLX and NASA-TLX metrics were subjectively evaluated by a surgeon and mentor at the end of each task. The scores given to performance and distraction metrics were used in the analyses here. Statistical test data were utilized to select EEG features that have a significant relationship with surgeon performance and distraction while carrying out a RAS surgical task in the OR. Results: RAS surgeon performance and distraction had a relationship with the surgeon’s functional brain network metrics as recorded throughout OR surgery. We also found a significant negative Pearson correlation between performance and the distraction level (−0.37, p-value < 0.0001). Conclusions: The method proposed in this study has potential for evaluating RAS surgeon performance and the level of distraction. This has possible applications in improving patient safety, surgical mentorship, and training.

Surgeon-Level Variation in Outcome following Esophageal Atresia Repair Is Not Explained by Volume

Introduction To assess whether there is a difference in operative outcome for esophageal atresia (EA) depending on a surgeon's seniority as defined by years in consultant practice or number of cases performed. In addition a Clavien–Dindo score was used to sequentially analyze the outcome of each surgeon's EA procedure. Materials and Methods All repairs performed over 22 years in an English regional center were analyzed. Outcomes were: death, anastomotic leak, need for dilatation, need for more than three dilatations, need for fundoplication, and a Clavien–Dindo adverse outcome of ≥3b. Possible explanatory variables were: number of prior repairs by the surgeon, surgeon's years of consultant experience. We also examined the effect of variables intrinsic to the infant as possible confounding variables and as independent predictors of outcome. Results A total of 190 repairs were performed or supervised by 12 consultants. There was no significant association between consultant experience and any objective outcome. However, sequential analysis suggests there is variation between surgeons in the incidence of Clavien–Dindo events of ≥3b. Performance showed deterioration in one case. Mortality was explicable by cardiac and renal anomalies. Conclusion There are surgeon-level variations in outcomes for the procedure of EA repair, but they are not explained by volume. Surgeon performance can deteriorate. Our study would not support the concept that patient outcomes could be improved by concentrating the provision of this surgery to fewer hospitals or surgeons.

Impact of data on generalization of AI for surgical intelligence applications

AI is becoming ubiquitous, revolutionizing many aspects of our lives. In surgery, it is still a promise. AI has the potential to improve surgeon performance and impact patient care, from post-operative debrief to real-time decision support. But, how much data is needed by an AI-based system to learn surgical context with high fidelity? To answer this question, we leveraged a large-scale, diverse, cholecystectomy video dataset. We assessed surgical workflow recognition and report a deep learning system, that not only detects surgical phases, but does so with high accuracy and is able to generalize to new settings and unseen medical centers. Our findings provide a solid foundation for translating AI applications from research to practice, ushering in a new era of surgical intelligence.

The Effect of Feedback on Surgeon Performance: A Narrative Review

Surgeons play a critical role in the healthcare community and provide a service that can tremendously impact patients’ livelihood. However, there are relatively few means for monitoring surgeons’ performance quality and seeking improvement. Surgeon-level data provide an important metric for quality improvement and future training. A narrative review was conducted to analyze the utility of providing surgeons direct feedback on their individual performance. The articles selected identified means of collecting surgeon-specific data, suggested ways to report this information, identified pertinent gaps in the field, and concluded the results of giving feedback to surgeons. There is a relative sparsity of data pertaining to the effect of providing surgeons with information regarding their individual performance. However, the literature available does suggest that providing surgeons with individualized feedback can help make meaningful improvements in the quality of practice and can be done in a way that is safe for the surgeons’ reputation.

A pilot study comparing ergonomics in laparoscopy and robotics: beyond anecdotes, and subjective claims

We aimed to use hand dexterity and grip strength test as objective measures to compare the difference in surgeon fatigue associated with robotic and laparoscopic colorectal surgery. We used the Purdue Pegboard Test to assess hand dexterity and the Camry Electronic Handgrip Dynamometer to assess hand grip strength. Eighteen patients were operated on, including 10 robotic and 8 laparoscopic cases. Statistical analysis revealed no difference in dexterity or muscle fatigue after operating with the robot. In contrast, there was a significant difference in the hand grip strength of both hands after laparoscopic surgery. Our results show that the resultant fatigue after laparoscopy affects both hands of the surgeon. In contrast, there was no difference in dexterity or muscle fatigue after operating with the robot. Given the demands of complex colorectal surgeries, robotics may be a means of optimizing surgeon performance by reducing fatigue.