Operative length independently affected by surgical team size: data from 2 Canadian hospitals.

BACKGROUND: Knowledge of the composition of a surgical team is the premise for studying efficiency inside the operating room. METHODS: To investigate the team composition in general surgery procedures, we retrospectively reviewed procedures performed by an expert general surgeon in 2007-08 at 2 tertiary hospitals. For each patient, demographic characteristics, procedure type, team members and procedure length were extracted from intraoperative nursing records. We assessed procedure complexity using a calculated index. Multiple logistic regressions were performed to assess the association between procedure length and team size after adjusting for procedure complexity and patient condition. RESULTS: For the 587 procedures reviewed, the mean procedure length was 88 (standard deviation [SD] 51) minutes. On average, 8 team members (range 4-14), including surgeons, anesthesiologists, nurses and other specialists, were involved in each procedure. Only 47 (8%) procedures were performed by 1 surgeon. Most were performed by 2 (295 [50%]) or 3 surgeons (214 [36%]). Half the team members were nurses (mean 4, range 1-7). Both the complexity of the operation and the team size affected the procedure length significantly. When procedure complexity and patient condition were constant, adding 1 team member predicted a 7-minute increase in procedure length. CONCLUSION: This study demonstrates that a frequent change of core team members has a negative impact on surgical performance. Management strategies need to improve to optimize team efficiency in the operating room.

Analysis of eye gaze: do novice surgeons look at the same location as expert surgeons during a laparoscopic operation?

INTRODUCTION: Eye-gaze technology can be used to track the gaze of surgeons on the surgical monitor. We examine the gaze of surgeons performing a task in the operating room and later watching the operative video in a lab. We also examined gaze of video watching by surgical residents. METHODS: Data collection required two phases. Phase 1 involved recording the real-time eye gaze of expert surgeons while they were performing laparoscopic procedures in the operating room. The videos were used for phase 2. Phase 2 involved showing the recorded videos to the same expert surgeons, and while they were watching the videos (self-watching), their eye gaze was recorded. Junior residents (PGY 1-3) also were asked to watch the videos (other-watching) and their eye gaze was recorded. Dual eye-gaze similarity in self-watching was computed by the level of gaze overlay and compared with other-watching. RESULTS: Sixteen cases of laparoscopic cholecystectomy were recorded in the operating room. When experts watched the videos, there was a 55% overlap of eye gaze; yet when novices watched, only a 43.8% overlap (p < 0.001) was shown. CONCLUSIONS: These findings show that there is a significant difference in gaze patterns between novice and expert surgeons while watching surgical videos. Expert gaze recording from the operating room can be used to make teaching videos for gaze training to expedite learning curves of novice surgeons.

Laparoscopic management of gastrointestinal stromal tumours: review at a Canadian centre.

BACKGROUND: Laparoscopic wedge resection has been widely accepted for small benign gastric tumours. Large gastrointestinal stromal tumours (GISTs), however, can be difficult to manipulate laparoscopically and are at risk for capsule disruption, which can then result in peritoneal seeding. Some authors have suggested that large GISTs (> 8 cm) are best approached using an open technique. However, there has been no consensus as to what the cut-off size should be. We conducted one of the largest Canadian series to date to assess outcomes and follow-up of the laparoscopic management of GISTs. METHODS: All patients with gastric GISTs presenting to Vancouver General Hospital and University of British Columbia Hospital between 2000 and 2008 were reviewed. Most lesions were resected using a wedge technique with closure of the stomach facilitated by an endoscopic linear stapling device. RESULTS: In all, 23 patients presented with GISTs; 19 patients underwent laparoscopic resection and, of these, 15 had a purely laparoscopic operation and 4 had a hand-assisted laparoscopic resection. Mean tumour size was 3.2 cm, with the largest tumour measuring 6.8 cm. There were no episodes of tumour rupture or spillage and no major intraoperative complications. All margins were negative. Mean follow-up was 13.3 (range 1-78) months. There was no evidence of recurrence or metastasis. CONCLUSION: The laparoscopic management of gastric GISTs is safe and effective with short hospital stays and good results over a mean follow-up of 13.3 months. We believe that it should be the preferred technique offered to patients.

An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura.

BACKGROUND: Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy. METHODS: Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups. RESULTS: A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group. CONCLUSIONS: The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.

Prospective comparison of early and late experience with laparoscopic adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy has gained acceptance in the treatment of adrenal tumors. We examine our initial 73 patients and highlight the change in patient selection and outcome that experience brings. METHODS: A prospective study from 2000 to 2005 enrolled 73 consecutive laparoscopic adrenalectomy patients at the University of British Columbia and Vancouver General Hospitals. RESULTS: Forty patients in an initial cohort and 33 in the follow-up group underwent adrenalectomy. The follow-up group had a greater proportion of pheochromocytomas (33.3% versus 7.5%), larger tumors (4.25 versus 1.97 cm), and higher American Society of Anesthesiologist (ASA) scores (2.82 versus 2.38) and lengths of stay (2.35 versus 1.55 days). Minor complication rates (12% versus 5%) were also higher. Operative times and blood loss were similar. Pheochromocytoma was associated with higher ASA scores and longer lengths of stay. Operative times and blood loss were not affected by diagnosis. CONCLUSIONS: Increasing experience in laparoscopic adrenalectomy allows broadening of indications to include a sicker patient population.