Toward reliable operative assessment: the reliability and feasibility of videotaped assessment of laparoscopic technical skills.

BACKGROUND: Decision making on the competency of surgical trainees to perform laparoscopic procedures has been hampered by the lack of reliable methods to evaluate operative performance. The goal of this study was to develop a feasible and reliable method of evaluation. METHODS: Twenty-nine senior surgical residents were videotaped performing a low anterior resection and a Nissen fundoplication in a pig. Ten blinded laparoscopists rated the videos independently on two scales. Rating time was minimized by allowing raters to fast-forward through the tapes at their discretion. Interrater reliability and the time required to rate a procedure were assessed. RESULTS: Rating time per procedure was a median of 15 min (range, 6-40). The mean interrater reliability for the two scales was 0.74. CONCLUSIONS: The use of videotapes of operations enabled multiple raters to assess a performance reliably and shortened assessment times by 80%. This assessment technique shows potential as a means of evaluating the performance of advanced laparoscopic procedures by surgical trainees.

Perfusion of the subarachnoid space in cadavers: a technique applicable for prevention of paraplegia in surgery of the thoracic aorta.

BACKGROUND: No safe technique of subarachnoid perfusion during thoracoabdominal aneurysm surgery has been described. We tested the hypothesis that in cold cadavers, perfusion of the subarachnoid space at the lumbar level with warm solution is feasible and increases the temperature at the thoracic level without an increase in cerebrospinal fluid (CSF) pressure. METHODS: Six cadavers were used. A 5 Fr silastic catheter in the subarachnoid space between the second and third lumbar vertebra (L2-3) was used as an inflow and a 16-gauge catheter at L4-5 as an outflow. Normal saline at 38 degrees C was infused at 999 mL/h. Temperatures of inflow and outflow, of the thoracic subarachnoid space (T8), and of the cisterna magna, were recorded. CSF pressures were measured from the outflow catheter. RESULTS: Outflow temperature was 9+/-1 degrees C at 10 minutes. At 15 minutes it was 27+/-4 degrees C, and thoracic subarachnoid temperatures was 22+/-5 degrees C. There was no statistical difference between the temperatures recorded at 10 and 15 minutes. The temperature of the cisterna magna was 8.5+/-1.2 degrees C at 15 minutes, significantly higher than the baseline (p=0.01), but lower than that at the T8 level (p=0.0001). CSF pressures during the experiment did not changed significantly from baseline and remained below 10 cm H20. CONCLUSIONS: The technique described is simple to implement, and effective in changing the temperature of the subarachnoid space at the thoracic level. Whether spinal cord cooling by this technique safely reduces the risk of paraplegia remains to be established in an animal model.

Randomized, controlled trial of bupivacaine injection to decrease pain after laparoscopic cholecystectomy.

OBJECTIVES: To determine if intraoperative instillation of bupivacaine would decrease early postoperative pain after laparoscopic cholecystectomy, if the patients would consequently require less narcotic postoperatively and if such patients would elect to be discharged on the day of operation if given the choice. DESIGN: Double-blind, randomized, controlled trial. SETTING: A tertiary care hospital in Hamilton, Ont. PATIENTS: Fifty patients underwent laparoscopic cholecystectomy. Day-surgery patients had the choice of staying overnight for discharge the following day. They were compared with a control group of 47 patients who had laparoscopic cholecystectomy but did not receive bupivacaine. INTERVENTION: Instillation of 20 mL of 0.5% bupivacaine with epinephrine into laparoscopic cholecystectomy port sites intraoperatively before closure. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores assessed 4 times postoperatively, the choice of patients to leave hospital the same day or to remain in the hospital overnight; the level of postoperative narcotic usage. MAIN RESULTS: Mean VAS pain scores (range 0 [no pain] to 5 [severe pain]) at less than 2 hours and at 6 hours after surgery were 2.9 and 2.9, respectively, in the bupivacaine group compared with 4.5 and 4.0, respectively, in the control group (p = 0.001 and 0.025). VAS scores at 10 hours postoperatively and the next morning did not differ between the groups. More patients in the bupivacaine group elected to go home on the day of surgery (p = 0.034). Narcotic usage was not significantly different. CONCLUSION: Instillation of bupivacaine into port sites should be standard practice for elective laparoscopic cholecystectomy.