Trained to cut? A literature review of veterinary surgical resident training.

A surgical residency trains veterinary graduates to a higher level of expertise in surgical procedures than is possible during veterinary school and prepares a resident to pursue board certification in surgery. The education of veterinary surgical residents has changed minimally since its inception in the twentieth century, and there are insufficient studies to determine if residency programs are producing surgeons with competence in each of the necessary procedural categories. The aims of this review were to report the current theory and methods used to provide surgical education to residents, to discuss the training most likely to create a competent, board-certified surgeon and to review assessment methods used during training. Several literature searches using broad terms such as "veterinary surgery residency," "veterinary surgery resident," and "veterinary surgical training" were performed using PubMed, CAB abstracts, and Google Scholar. Literature pertinent to theory, methods, training, and assessment of veterinary surgical residents was included. The reviewed literature demonstrated the need for research-based learning curves for specific procedures. Simulation training is known to facilitate deliberate practice and should be leveraged where possible to reach competency. The creation of validated assessment methods should be pursued as it enables assessment of competency instead of inferring its development from case logs. Understanding and supporting learner cognition and providing sufficient feedback remain important issues in the field. Surgical educators are urged to continue to search for innovative and evidence-based ways to train competent surgical residents.

Attitudes towards surgical safety checklists among American College of Veterinary Surgeons diplomates.

OBJECTIVE: To examine attitudes towards surgical safety checklists (SSCs) among American College of Veterinary Surgeons (ACVS) diplomates and to identify barriers to implementation. STUDY DESIGN: Qualitative online research survey. SAMPLE POPULATION: A total of 1282 current ACVS diplomates. METHODS: An anonymous online survey was distributed to current ACVS diplomates via email. ACVS diplomates were identified using publicly available data through the ACVS website. A total of 1282 surveys were electronically distributed, and respondents were given 4 weeks to respond. The survey consisted of 34 questions examining (1) demographic information, (2) current use of SSCs, (3) knowledge and attitudes towards SSCs, (4) perceived advantages and disadvantages to use of SSCs, (5) implementation strategies, and (6) potential reasons for noncompletion of SSCs. RESULTS: Survey response rate was 20% (257/1282). A total of 169 of 249 (67.9%) respondents indicated using SSCs. Respondents generally agreed that SSCs were proven to reduce surgical complications (196/249 [78.7%]) and did not perceive any disadvantages to use (100/138 [75.2%]). Respondents not using SSCs were more likely to perceive them as a waste of time (p < .001). The most common reasons for noncompletion of SSCs were forgetfulness (21/52 [39.6%]) and time constraints (19/52 [36.5%]). Improved training (72/138 [52.2%]) and modifying the SSC based on staff feedback (69/138 [50%]) were suggested as methods to improve SSC uptake. CONCLUSION: Respondents currently using SSCs were generally satisfied. Time constraints and memory related issues were common causes for noncompletion of SSCs. CLINICAL SIGNIFICANCE: Efforts to expand the implementation of SSCs in veterinary surgery should focus on improved engagement of relevant stakeholders and modification of the SSC to suit local conditions.

Evaluation of a laparoscopic abdominal simulator assessment to test readiness for laparoscopic ovariectomy in live dogs.

OBJECTIVE: To predict readiness for laparoscopic ovariectomy of live dogs on the basis of performance on a high-fidelity laparoscopic abdominal simulator and to determine interrater reliability of the assessment. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Seventeen fourth-year veterinary students. METHODS: After a standardized laparoscopic training course, each participant performed a laparoscopic ovariectomy with a simulator. This performance was scored in real time by two evaluators using a rubric. Participants achieving a score of 112 of 160 performed a laparoscopic ovariectomy in a live dog, supervised by an instructor in the room. Two evaluators scored video recordings of each procedure using the rubric. Participants' opinions about the simulator were collected with a survey. RESULTS: All participants scored above the threshold (range, 126-151) and successfully completed laparoscopic ovariectomy in a live dog, with an average of 10 of 17 participants requiring verbal guidance and 5 of 17 participants requiring intervention from the instructor. Interrater concordance was excellent for the rubrics used to score performance on the simulator (R = 0.91) and in vivo (R = 0.81). All participants agreed that the simulator should be used to assess trainee readiness prior to surgery in a live dog. CONCLUSION: Participants achieving a score of at least 126 of 160 on the simulator were able to perform a laparoscopic ovariectomy in a live dog under supervision. The scoring system for the simulator had excellent interrater concordance. CLINICAL SIGNIFICANCE: This simulator and scoring system can be used in laparoscopic training programs to assess readiness for progression to the operative setting.

Using Creativity as an Educational Tool in Veterinary Surgery: Students' Perceptions and Surgical Performance.

With the aim of improving students' ability to handle the complexity of surgery, we introduced a creative assignment in a veterinary surgical course. We hypothesized that by using this active, inductive educational method, reflection, creativity and self-efficacy in student novice surgeons could be improved. During a companion animal surgical course an intervention group was investigated against a control group. Twenty-nine fourth-year students were instructed in ovariohysterectomy by classical lectures, while 23 fourth-year students were provided with creative materials and assigned to consider and illustrate how to perform the procedure themselves. Surgical performance was assessed for both groups using a modified Objective Structured Assessment of Technical Skills (OSATS) while performing a simulated ovariohysterectomy. Furthermore, both groups were investigated with respect to how they would handle a specific hypothetical surgical complication. Semi-structured interviews were conducted with 17 intervention-group students and were analyzed using thematic analysis. The intervention group showed a significantly better performance and needed significantly less help with the surgical complication than the control group students. Data from interviews furthermore demonstrated that students believed the creative intervention produced increased reflection, more creative initiatives, and a feeling of security before surgery. Our study results thus indicate that an educational tool which stimulates creative thinking can promote reflection, creativity, and self-efficacy in novice surgeons without compromising surgical performance.

Guidelines for Implementing a Low-Cost Volunteer Desexing Skills Training Program for Veterinary and Veterinary Technology Students.

Although desexing surgeries are considered a core clinical skill for small animal veterinary practice, it can be challenging for veterinary schools to provide students with adequate training opportunities in the traditional curriculum. At the Massey University School of Veterinary Science, we recently established an innovative extracurricular volunteer program designed to have students teaching other students how to perform different elements of desexing procedures as they progress through their degree. This program includes administrative and assistant roles for first-year students (responsible for client communication, patient restraint, and medical record keeping), physical exam and recovery roles for second-year students (responsible for assessing patient fitness for surgery, drawing up anesthetic drugs, and monitoring patients in recovery), anesthesia and neuter surgeon roles for third-year students (responsible for inducing, preparing, and monitoring spay patients and performing cat neuter surgeries), and spay surgeon roles for fourth- and fifth-year students (responsible for performing cat spay surgeries, discharging patients, and following up with clients to monitor recovery). This program has been successful in improving student confidence and competence while also providing a valuable low-cost desexing service to the community. In this article, we discuss the practical considerations and processes involved in implementing this program, including mapping the existing surgical curriculum, recruiting patients, setting up the surgical facilities, purchasing equipment and supplies, establishing standard operating procedures, developing training materials, maintaining clinic records, and monitoring program outcomes. These resources can serve as guidelines for other veterinary schools looking to expand desexing surgery training opportunities for students.

Survey of surgical specialists' content preferences in radiology reports for extrahepatic portosystemic shunts.

The aim of this prospective, survey study was to assess the opinions of specialist surgeons as to the preferred content, nomenclature, and classification of extrahepatic portosystemic shunts for inclusion in radiology reports. A link to an online survey was sent by email to members of the European College of Veterinary Surgeons and the Association of Veterinary Soft Tissue Surgeons, and was made available on the American College of Veterinary Surgeons web forum and Facebook page. There were 93 respondents (survey sent to over 2500 email addresses and made available in two online locations). Most respondents agreed that they both review the images themselves (87/92, 95%) and read the radiology report (82/92, 89%) prior to surgery. Most respondents believed that the radiology report should contain a detailed anatomic description of the insertion (83/92, 90%), origin (54/91, 59%), and course (70/92, 76%) of the shunt, as well as a measure of the diameter of the shunting vessel at its insertion (54/92, 59%). Most respondents (70/90, 78%) disagreed that a brief description of shunt type, such as portocaval or portophrenic, was sufficient. Respondents were undecided regarding the use of an alphanumeric classification system (36/92, 39% agree; 32/92, 35% disagree). There was agreement that details of the presence or absence of urolithiasis (91/93, 98%), renomegaly (54/93, 58%), and peritoneal fluid (72/92, 78%) should be included in the report. The results of this study will help to guide reporting radiologists in providing descriptions of extrahepatic portosystemic shunts that include information most preferred by the recipient surgeons.

Evaluation of a method to assess digitally recorded surgical skills of novice veterinary students.

OBJECTIVE: To evaluate a method to assess surgical skills of veterinary students that is based on digital recording of their performance during closure of a celiotomy in canine cadavers. SAMPLE POPULATION: Second year veterinary students without prior experience with live animal or simulated surgical procedure (n = 19) METHODS: Each student completed a 3-layer closure of a celiotomy on a canine cadaver. Each procedure was digitally recorded with a single small wide-angle camera mounted to the overhead surgical light. The performance was scored by 2 of 5 trained raters who were unaware of the identity of the students. Scores were based on an 8-item rubric that was created to evaluate surgical skills that are required to close a celiotomy. The reliability of scores was tested with Cronbach's α, intraclass correlation, and a generalizability study. RESULTS: The internal consistency of the grading rubric, as measured by α, was .76. Interrater reliability, as measured by intraclass correlation, was 0.64. The generalizability coefficient was 0.56. CONCLUSION: Reliability measures of 0.60 and above have been suggested as adequate to assess low-stakes skills. The task-specific grading rubric used in this study to evaluate veterinary surgical skills captured by a single wide-angle camera mounted to an overhead surgical light produced scores with acceptable internal consistency, substantial interrater reliability, and marginal generalizability. IMPACT: Evaluation of veterinary students' surgical skills by using digital recordings with a validated rubric improves flexibility when designing accurate assessments.

Experience and confidence of final year veterinary students in performing desexing surgeries.

AIMS: To describe the level of experience and confidence of veterinary students in performing canine and feline desexing procedures at the end of their final clinical year. METHOD: A cross-sectional survey was conducted with veterinary students at Massey University in November 2017 after completion of their final clinical year. The questions included career plans after graduation, number of assisted and unassisted desexing procedures performed, approximate time to complete desexing surgeries, level of confidence with different aspects of desexing surgeries, what aspects of their desexing surgery training were most helpful, and what could be done to improve training in desexing surgical skills in veterinary school. RESULTS: The survey was completed by 70/95 (74%) students in their final clinical year. Among respondents, 55/70 (70%) had performed >2 unassisted feline neuters before graduation. However 38/70 (54%) students had never performed an unassisted feline spay, 31/70 (44%) had never performed an unassisted canine neuter, and 44/70 (63%) students had never performed an unassisted canine spay. The median reported times to complete a feline neuter, feline spay, canine neuter, and canine spay were 9, 40, 30 and 60 minutes, respectively. The median level of confidence for these procedures were 9, 6, 7 and 5 (on a scale from 1=least confident to 10=most confident), respectively. The reported time to complete procedures and the confidence in performing procedures did not change markedly with increasing total number of procedures performed. Students were most concerned about their ability to perform the desexing procedures in a reasonable amount of time and to prevent post-operative bleeding from occurring. Students were least concerned with their ability to manage post-operative pain in patients and to select the appropriate suture material. Free-text comments revealed that 62/70 (89%) students wanted more hands-on surgical experience prior to graduation. CONCLUSION AND CLINICAL RELEVENCE: Many students are currently completing veterinary school with limited experience and low confidence with performing routine canine and feline desexing procedures. Further research is needed to identify the most effective ways for addressing this issue within the constraints of the veterinary curriculum and teaching hospital resources.

Comparison of Veterinary Student Ability to Learn 1-Handed and 2-Handed Techniques for Surgical Knot Tying.

OBJECTIVE: To determine which type of surgical hand-tie trainee surgeons learn most readily in a laboratory setting, using a combination of audiovisual demonstration and one-on-one teaching. STUDY DESIGN: Randomized controlled learning trial. SAMPLE POPULATION: Year 4 veterinary students in their 1st year of clinical training (n = 58). METHODS: Veterinary students entering clinical rotations were randomly allocated to 2 learning groups: 1-handed (28 students) or 2-handed (30 students) surgical ties. Knot tying technique was taught followed by three 15-minute practice sessions with student progress recorded by filming each student tying a square knot (2 throws). All 3 knot tying attempts were scored for technique and knot formation. Data on potential confounding factors between groups, including age and gender, were recorded. RESULTS: There were no significant differences between group scores for each attempt (1st attempt P = .5; 2nd P = .2; 3rd P = .19). Initially, scores indicated more rapid learning in the 1-handed group but fewer individuals achieved a perfect technique and knot after 60 minutes of learning (29/30 for 2-handed; 24/28 for 1-handed group). The 1-handed group was the most error-prone (after 45 minutes P < .01; after 60 min P < .01). CONCLUSIONS: Over 95% of students in the 2-handed group performed the technique and knot perfectly after 60 minutes learning time; were significantly less error-prone and fewer students continued to make corrected errors after 60 minutes. This evidence indicates that the 2-handed technique allows students to achieve success in a manageable teaching time.

Observational study of patient and surgeon preoperative preparation in ten companion animal clinics in Ontario, Canada.

BACKGROUND: Surgical site infections (SSIs) are a recognized risk of any surgical procedure in veterinary medicine. One of the keys to prevention of SSIs is reducing exposure of the surgical site to endogenous and exogenous microbes, beginning in the preoperative period. While guidelines are available for preoperative preparation procedures, there has been no objective investigation of compliance with these recommendations in veterinary practices. The objectives of this pilot study were to describe preoperative patient and surgeon preparation practices in a sample of non-equine companion animal veterinary clinics, and to determine if there were any areas that consistently did not meet current guidelines. RESULTS: Observation of preparation practices was performed in 10 clinics over 9-14 days each using up to 3 small wireless surveillance cameras. Data were coded for 148 surgical patients, and 31 surgeons performing 190 preoperative preparations. When patient hair removal was observed, it was most commonly done using clippers (117/133, 88%), and in only one case was it performed prior to anesthetic induction. Patient contact time with soap ranged from 10-462 s (average of clinic means 75 s, average of clinic medians 67 s), and with alcohol from 3-220 s (average of clinic means 44 s, average of clinic medians 37 s). Alcohol-based hand rub (AHR) was used preoperatively in 2/10 facilities, but soap-and-water hand scrub was most commonly used at all clinics. Proximal-to-distal scrubbing was noted in 95/142 (67%) of soap-and-water scrubs. Contact time during surgeon hand preparation ranged from 7-529 s (average mean 121 s, average median 122 s) for soap-and-water and from 4-123 s (average mean 25 s, average median 19 s) for AHR. No significant changes in practices were identified over time during the observation period. Practices that did not conform to guidelines available in major companion animal surgical textbooks were commonly observed. CONCLUSIONS: Some preoperative preparation practices were relatively consistent between clinics in this study, while others were quite variable. Contact times with preoperative preparatory solutions for both patients and surgeons were often shorter than recommended. Evidence-based guidelines for these procedures in veterinary medicine should be established and implemented in order to help reduce preventable SSIs, while maintaining efficiency and cost-effectiveness.

Comparison of two surgical site protocols for cattle in a field setting.

OBJECTIVE: To compare 2 preoperative surgical site protocols for standing laparotomy in cattle in a field setting. STUDY DESIGN: Cohort study. ANIMALS: Dairy cows (n = 73) undergoing a clean standing laparotomy (no visceral perforation during surgery). METHODS: Cows were randomly assigned to 1 of 2 preoperative skin-preparations protocols with chlorhexidine used as an antiseptic. A standard protocol (3 minutes [min] cleansing scrub, tap water rinse, 3 minutes surgical scrub with a sterile one-use chlorhexidine scrub and alternate passage of alcohol and 2% chlorhexidine solution (7 minutes; n = 32) was compared with a 3 minutes abbreviated preoperative protocol, consisting of two 90 seconds period of cleansing scrub and 3 passages of 0.5% chlorhexidine gluconate in 70% in isopropyl alcohol solution (4 minutes; n = 32). Pre- and postoperative skin bacterial counts and clinical assessment of wounds 10-15 days after surgery, as well as standardized interview with the producers focused on wound infection 30 days after the surgery were used to compare both protocols. RESULTS: There was no difference between protocols for absolute colony forming units (CFU) and percentage CFU reduction perioperatively as well as for surgical wound clinical score 10-15 days after the surgery. The infection rate at 30 days was 10.5% (6/57) but no significant difference was observed between protocols 10% (3/30) versus 11.5% (3/27). CONCLUSIONS: An abbreviated preoperative protocol using nonsterile reusable material can be as effective as a standard protocol using sterile one-use brush in reducing skin microflora and preventing surgical wound infection.

Expected frequency of use and proficiency of core surgical skills in entry-level veterinary practice: 2009 ACVS core surgical skills diplomate survey results.

OBJECTIVES: ACVS Diplomates were surveyed to identify a complete list of core surgical skills, determine the expected frequency of use of these skills, and ascertain the level of skills proficiency expected of entry-level practicing veterinarians. STUDY DESIGN: Internet-based survey. SAMPLE POPULATION: Randomly chosen ACVS Diplomates (n = 750). METHODS: Rating scale items were used to construct the main portion of the survey with 26 skills that were scored by participants based on rankings of proficiency expected of entry-level veterinarians, as well as expected frequency of use of these skills. Additional demographic questions were included to gather information regarding gender, practice type, year of veterinary school, year of ACVS membership, job description, primary surgical discipline, practice location, average number of procedures performed on a weekly basis, and number of new graduates mentored in the last 5 years. RESULTS: Of 337 Diplomates (44.9%) who responded to the survey, >60% expected entry-level graduates to have good skills with minimal supervision or complete skills for 21 of the 26 skills categories listed. More than 60% of respondents ranked 7 skills with a lower frequency score (seldom or occasionally use). Orthopedic instrument handling and fixation skills as well as electrosurgical and laser skills received some of the lowest expected proficiency and frequency rankings. No additional skills categories were identified in the open-ended survey questions. CONCLUSIONS: A complete list of core surgical skills was identified. There was broad consensus between boarded surgeons irrespective of their practice type, experience, or discipline for ranked proficiency and frequency scores among the core surgical skills expected of entry-level veterinarians.

The quadriceps angle: reliability and accuracy in a fox (Vulpes vulpes) pelvic limb model.

OBJECTIVES: To evaluate the effect of measurement technique and limb positioning on quadriceps (Q) angle measurement, intra- and interobserver reliability, potential sources of error, and the effect of Q angle variation. STUDY DESIGN: Cadaveric radiographic study and computer modeling. ANIMALS: Pelvic limbs from red foxes (Vulpes vulpes). METHODS: Q angles were measured on hip dysplasia (HD) and whole limb (WL) view radiographs of each limb between the acetabular rim, mid-point (Q1: patellar center, Q2: femoral trochlea), and tibial tuberosity. Errors of 0.5-2.0 mm at measurement landmarks alone and in combination were modeled to identify the effect on Q angle. The effect of measured Q angles on the medial force exerted on the patella (F(MEDIAL)) was calculated. RESULTS: The HD position yielded significantly (P < .001) more medial Q angles than the WL position. No significant difference was observed between Q1 and Q2, but Bland-Altman plots indicated they were not equivalent. Intra- and interobserver agreement was substantial. Q2 errors were inherently greater than Q1: the mid-point and tibial tuberosity are the most important sources of Q angle variability. Increasing Q angles significantly increased the exerted F(MEDIAL) (P < .0001, gradient 1.7%). CONCLUSIONS: Measurements are reliable, but Q2 is more prone to error than Q1, and the 2 measurement techniques are not interchangeable. Positional errors must be kept below 1.3 mm (Q1) or 0.8 mm (Q2).

Emotions in veterinary surgical students: a qualitative study.

A surgical educational environment is potentially stressful and can negatively affect students' learning. The aim of the present study was to investigate the emotions experienced by veterinary students in relation to their first encounter with live-animal surgery and to identify possible sources of positive and negative emotions, respectively. During a Basic Surgical Skills course, 155 veterinary fourth-year students completed a survey. Of these, 26 students additionally participated in individual semi-structured interviews. The results of the study show that students often experienced a combination of emotions; 63% of students experienced negative emotions, while 58% experienced positive ones. In addition, 61% of students reported feeling excited or tense. Students' statements reveal that anxiety is perceived as counterproductive to learning, while excitement seems to enhance students' focus and engagement. Our study identified the most common sources of positive and negative emotions to be "being able to prepare well" and "lack of self-confidence," respectively. Our findings suggest that there are factors that we can influence in the surgical learning environment to minimize negative emotions and enhance positive emotions and engagement, thereby improving students' learning.

Evaluation of a brief video intervention aimed at UK-based veterinary surgeons to encourage neutering cats at four months old: A randomised controlled trial.

In the UK, it is currently recommended that owned cats be neutered from four months of age. However, its uptake is inconsistent across the veterinary profession. Here we assess the effect of a brief video intervention that aimed to encourage four month neutering, whilst preserving clinical autonomy. We compare this theory-driven approach with traditional information giving and a control group. Veterinary surgeons who regularly undertook feline neutering work in the UK but did not routinely neuter cats at four months and/or recommend four month neutering for client owned cats were randomised into three groups (n = 234). Participants received either no information, a written summary of evidence or the video. The primary behaviour outcomes were the recommending and carrying out of neutering cats at four months. Evaluative, belief and stages of change measures were also collected. Self-reported outcomes were assessed pre-intervention, immediately post-intervention, two months post-intervention and six months post-intervention. At two months, participants that had received the video intervention were significantly more likely to have started recommending neutering cats at four months. At six months, participants that had received the video intervention were significantly more likely to have started carrying out neutering cats at four months. There were no significant behaviour changes for the other groups. At two months, the video intervention was associated with a significant increase in thinking about, and speaking to colleagues about, four-month neutering, relative to the control group. The written summary of evidence had no similar effect on stages of change, despite it being perceived as a significantly more helpful resource relative to the video. To conclude, a brief one-off video intervention resulted in an increase in positive behaviours towards neutering cats at 4 months, likely mediated by the social influences of the intervention prompting the opportunity to reflect and discuss four-month neutering with colleagues.

The creation of an international audit and database of equine colic surgery: survey of attitudes of surgeons.

REASONS FOR PERFORMING STUDY: Currently, there is a lack of available evidence-based data concerning the optimum treatments for horses affected by different types of colic and this precludes the application of clinical audit in this area. In order to accumulate such data, a large-scale, multicentre database of the outcomes of colic surgery is proposed. The attitudes of surgeons is an important consideration in determining the feasibility of developing this database. OBJECTIVES: To assess attitudes and opinions of equine surgeons concerning clinical audit and to assess the perceived advantages and problems of setting up a large-scale international audit/database of colic surgery. METHODS: Interviews were conducted with 30 equine surgeons (large animal/equine surgeons who are diplomates of either the American College of Veterinary Surgeons or the European College of Veterinary Surgeons). Questionnaires were sent by e-mail to 98 equine surgeons. RESULTS: Face to face interviews were conducted (n = 30) and 43/98 completed questionnaires received (44%). The results of the 2 techniques were very similar. There was generally a high level of interest in the development of a large scale database of colic surgery, but perceived problems included time to collect and submit data, and confidentiality issues. A minority of surgeons reported that they were undertaking any form of specific monitoring of the results of colic surgery within their hospitals. CONCLUSIONS: There is a good level of interest among equine surgeons to develop a large scale database of colic surgery and most would be willing to contribute data from their own hospitals provided that data collection is quick and easy, and that confidentiality is maintained.

Umbilical surgery in calves.

Calves benefiting from umbilical surgery can be affected by several different conditions. However, the practitioner should be able to correct any of these conditions surgically, especially in young calves, as a field procedure. Like other aspects of veterinary practice, the individual must decide what services he/she wishes to offer clients in the field or clinic setting and which ones will be referred. The objective of this article is to equip practitioners who wish to treat umbilical masses surgically with the information they need.

Complications of surgery for diseases of the guttural pouch.

Guttural pouch diseases pose serious challenges in diagnosis and treatment. Complications from treatment are common and often life-threatening, largely because the unique anatomy of the guttural pouches brings them into intimate contact with the nervous, respiratory, and cardiovascular systems. There is little forgiveness for surgical errors, and so the surgeon should focus on ways to anticipate and prevent them. As with any disease, errors in diagnosis can set the stage for many surgical errors and must be recognized. This article deals with errors that can be expected after the most common surgical treatments for guttural pouch diseases.

Complications of laparoscopic surgery.

This article describes surgical complications associated with laparoscopy, how to avoid them, how to recognize them if they do happen, and how to deal with them in the most expedient method possible. Complications of sedation, anesthesia, positioning, the general surgical approach, and complications associated with specific surgical procedures are examined. The best defense against surgical complications is a thorough training program and an understanding of anatomy that will help the surgeon work in the three-dimensional environment while being limited to two dimensions on the monitor. The author concludes that it is critical to be able to convert the surgery to an open procedure if there are problems with the equipment or the patient.