Legal & ethical dilemmas in incidental findings during surgery: Review article.

BACKGROUND: Discovering IF (incidental findings) during surgery results in ethical and legal dilemmas for the surgeon, especially those in training or recently qualified. The situation is further compounded as these can occur in an emergency. The immediacy of making the correct decision can be paramount for both the surgeon and the patient. METHODS: Firstly, this article will review the ethical and legal frameworks of IF during surgery for those unfamiliar on the literature. Secondly, it will evaluate the use of a proposed IF tool to illustrate the decision-making processes in published case reports for those unfamiliar to the process. After the above two have been completed, a decision-making IF guidance tool will be constructed, which could help educate trainee surgeons. RESULTS: The ethical and legal frameworks include the Hippocratic oath, domestic and European legislation, case law, civil and criminal laws. In the evaluated case reports there were IF which were either life-threatening or affecting the immediate life of the patients. 90% of the cases were emergency and 10% were elective operations. Using the proposed IF tool and combining it with peer-reviewed published best practice, 60% of the cases were correct in their intra-operative decision-making. This demonstrates the need of some type of guidance on the subject. As a consequence of these results, the article describes the construction of an IF decision-making guidance tool. The essential components of the guidance tool involve decision-making, the inference from other medical fields, ethical and legal elements, the available experience, skills and specialist knowledge at the time, best clinical practice and post-operative management and counselling. CONCLUSIONS: On finding an IF during surgery, the surgeon must balance the ethical dilemmas of autonomy, beneficence, justice, and non-maleficence for the patient. This is further complicated by applying these principals to current civil and criminal laws. By constructing an IF guidance tool may assist in improving patient safety and help the trainee and newly qualified surgeon and his team to come to the correct decisions in the best interests of the patient.

Validation of open inguinal hernia repair simulation model: a randomized controlled educational trial.

BACKGROUND: A hernia repair open surgical simulation computer software was developed at Imperial College London. A randomized controlled educational trial was conducted to investigate the benefit of the simulation on the development of procedural knowledge. METHODS: Medical students in their clinical years were invited to participate in the trial. Students were block randomized to 4 groups: G1--Interactive Simulation; G2--Non-interactive Simulation; G3--Video Tutorial; G4--Control. On completion, they were objectively assessed on their ability to recall the tasks involved in an open inguinal hernia repair in the form of a multiple choice question (MCQ) and a simulated discussion with a consultant surgeon. RESULTS: Fifty-six students completed the study. Each arm carries similar baseline scores (pre-intervention MCQ) with means 43.33, 38.92, 38.33, and 39.57 in G1 to G4, respectively. MCQ score improvements and final assessment scores proved better in the intervention groups (1, 2, and 3) compared to controls. CONCLUSION: The interactive simulation has shown an objective benefit in teaching medical students the anatomical and procedural knowledge in performing an open inguinal hernia repair.

Simulation in surgery: a review.

The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss the importance of surgical simulation today and its various types, exploring the effectiveness of simulation in the clinical setting and its challenges for the future. Surgical simulation offers the opportunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that skills acquired through training with simulators, positively transfers to the clinical setting and improves operative outcome. The major challenge for the future revolves around understanding the value of this new technology and developing an educational curriculum that can incorporate surgical simulators.

Open surgery simulation of inguinal hernia repair.

Inguinal hernia repair procedures are often one of the first surgical procedures faced by junior surgeons. The biggest challenge in this procedure for novice trainees is understanding the 3D spatial relations of the complex anatomy of the inguinal region, which is crucial for the effective and careful handling of the present anatomical structures in order to perform a successful and lasting repair. Such relationships are difficult to illustrate and comprehend through standard learning material. This paper presents our work in progress to develop a simulation-based teaching tool allowing junior surgeons to train the Lichtenstein tension-free open inguinal hernia repair technique for direct and indirect hernias, as well as to enforce their understanding of the spatial relations of the involved anatomy.

Feasibility of self-appraisal in assessing operative performance in advanced laparoscopic colorectal surgery.

AIM: To date there has been no attempt to assess comprehensively generic and specific technical skills in live advanced laparoscopic colorectal surgery. In this study, we aim to develop and validate a new tool which can assess these skills. METHOD: Weighted Likert scales were constructed individually for generic and specific technical skills on three key laparoscopic colorectal operations: right hemicolectomy, sigmoid colectomy and anterior resection, after expert discussions. RESULTS: Fifty-two live operations were assessed, performed by four consultants and six trainees. The interclass correlation coefficient between the operating surgeon and first assistant was 0.94, P ≤ 0.05 for generic technical skills and 0.88, P ≤ 0.05 for the specific technical skills. Construct validity for both generic and specific technical skills for consultants and trainees were significant using ANOVA, P ≤ 0.05. CONCLUSION: This new assessment tool of technical skills in laparoscopic colorectal surgery is reliable, has face content, concurrent and construct validities. The tool could be used as an instant surgical training tool and avoids watching videos retrospectively.

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool.

AIMS: The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees. METHODS: Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently. RESULTS: Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann-Whitney for generic technical skills was significant for live and simulated operations, P < or = .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann-Whitney P < .05, but not for supervised live operations, Mann-Whitney P > .05. CONCLUSIONS: The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.

Procedural performance in gastrointestinal endoscopy: live and simulated.

BACKGROUND: The purpose of the present study was to compare the use of a human and a computer-based technical skills assessment tool in live and simulated gastrointestinal endoscopies performed by consultants and trainees. METHODS: Validated human-based Likert scales were used individually for generic and specific technical skills for two procedures. Two observers assessed each procedure independently and blindly. Computer-based assessment tools were also used, assessing aspects of the mucosa as well as various procedural times. The two tools were then compared. RESULTS: A total of 210 live and simulated endoscopies (107 esophagogastroduodenoscopy [OGD], 103 sigmoidoscopy) were performed by 18 consultants and 37 trainees. Mean inter-rater reliability using Cronbach alpha was good for the human-based tool (range: p = 0.62-0.75). Construct validity was good for the human-based tool (analysis of variance [ANOVA] range: p = 0.000-0.002) but not for the computer-based tool (ANOVA range: p = 0.263-0.701). CONCLUSIONS: This human-based technical skills assessment tool of gastrointestinal endoscopies seems to have face, content, concurrent, and construct validities compared to computer-based assessment parameters. The tool has the possibility of being used in training, self-appraisal, and revalidation.

Assessing operative performance in advanced laparoscopic colorectal surgery.

BACKGROUND: Competent technical skills performance in complex operations is vital for satisfactory patient outcome. Assessing these skills is therefore of paramount importance. In this study we aim to develop and validate a new tool that can assess both generic and specific technical skills in advanced complex laparoscopic colorectal surgery in the operating room. METHODS: Hierarchical task analysis was constructed for generic and specific technical skills on three key advanced laparoscopic colorectal operations (right hemicolectomy, sigmoid colectomy, and anterior resection) after expert discussions. Likert scales were then constructed individually for generic and specific technical skills for each operation using hierarchical task analysis for each operation to identify key elements and steps for each operation. Each operation was assessed independently and blindly by two experienced surgeons. RESULTS: Eighty-four live real operations performed by six consultants and eight trainees were assessed. Interclass correlation coefficient between the two observers was 0.94 (P < or = 0.05) for generic technical skills and 0.88 (P < or = 0.05) for the operation-specific technical skills. Construct validity for both generic and specific technical skills for consultants and trainees was significant using ANOVA (P < or = 0.05). All consultants therefore consistently performed better in both generic and specific technical skills compared to their trainees. CONCLUSIONS: This new assessment tool of generic and specific technical skills in advanced laparoscopic colorectal surgery is reliable and has face, content, concurrent, and construct validities. The tool has the possibility of being used as a surgical training and appraisal tool.

A decision-making learning and assessment tool in laparoscopic cholecystectomy.

AIMS: Making correct decisions is an integral part of surgical competency and excellence. The learning of this expert skill takes years to accumulate during training. To date there has not been an attempt to accelerate this learning process by developing a tool. In our present study we develop a self-appraisal computer software learning and assessment decision-making tool for laparoscopic surgery. It aims to accumulate several years of varied surgical experience, so the trainee can start to learn the complexities of surgical decision making in various types of cases. In this study we aim to validate the tool. METHODS: Three decision-making modules were developed in a computer program for laparoscopic cholecystectomy: knowledge of operation, operative surgical technique and operative task completion. The latter two modules were based on answering questions based on watching recorded live operations from a library of 100 recorded laparoscopic cholecystectomies of various grades. The questions were devised by two experienced surgeons with more than 14 years postgraduate surgical experience. To validate the tool two groups with varying surgical experience were assessed: intermediate and expert surgeons. These groups were determined by the number of laparoscopic cholecystectomies performed as well as of number of years of operative surgical experience. RESULTS: A total of 20 subjects were assessed, 12 intermediate and 8 experts surgeons. Mean time to perform the programme was 21 min (range 18-45 min). Using the Mann-Whitney test, p < 0.05, construct validity was demonstrated in the surgical technique and completion of task modules as well as the total combined scores. CONCLUSIONS: Our computer-based decision-making learning tool for laparoscopic cholecystectomy seems to have face, content, concurrent and construct validities. Surgical decision making is a multifaceted process; by assessing how and why decisions are made effectively, focussed surgical training may be achieved. We aim in the future to determine if the self-appraisal decision-making tool improves or accelerates surgical training.

Procedural performance in gastrointestinal endoscopy: an assessment and self-appraisal tool.

AIMS: Assessing endoscopic technical skills competency in a structured manner is a topical issue, in light of several workforce factors that may affect the training of future endoscopists. To date there has been little attempt to comprehensively assess both generic and specific technical skills in lower gastrointestinal endoscopies; the current study aimed to develop and validate a tool that can assess these varied skills. METHODS: Hierarchical task analyses of generic and specific technical skills were constructed on flexible sigmoidoscopy and colonoscopy after expert panel discussions. Generic technical skills are subtasks (eg, movements of the control wheel) that allow the endoscopist to complete a main task (specific technical skills), for example, reaching the cecum. Weighted Likert scales were then constructed individually for generic and specific technical skills for each procedure. Two observers assessed each procedure independently. RESULTS: A total of 135 endoscopic procedures were performed by 9 consultants and 12 registrars. Mean inter-rater reliability Cronbach alphas were .83 and .80, P < or =.05, for generic and specific skills, respectively, for each procedure. Construct validity results using analysis of variance (ANOVA) for consultants and trainees were significant for each procedure, P = .005, P = .003 for generic, and P = .012, P = .004 for specific technical skills. CONCLUSIONS: This new assessment/self-appraisal tool for lower gastrointestinal endoscopies seems to have face, content, concurrent, and construct validities. The tool has the possibility of being used in training and self-appraisal. We aim to modify and apply this tool to other endoscopic procedures in the future, such as endoscopic retrograde cholangiopancreatography (ERCP), endoluminal and transluminal procedures.

Decision making in laparoscopic surgery: a prospective, independent and blinded analysis.

AIMS: Correct decision making is pivotal and an integral part of surgical competency. To date there has not been an attempt to assess surgeons making decisions whilst operating. In our present study we aim to assess operative decision making by trainee and expert surgeons by using hierarchical task analysis (HTA) as a method to map out decision making in surgery. METHODS: One hundred and forty live laparoscopic operations were prospectively analyzed, independently and blindly. The operations were compared to an operative HTA, and individual case reasons for deviations noted. Factors in the operating theatre which may influence the surgeons' decisions whilst operating were assessed using a checklist. RESULTS: One hundred and nineteen elective and 21 emergency laparoscopic operations performed by 12 consultants and 14 registrars were analysed. Factors from the HTA and theatre environment checklists were categorised. Inter-rater reliability was k=0.95, k=1.00 for sub-tasks and tasks, respectively, and 0.98 between the surgeon and independent observer for the operating theatre checklist. From these data sets a psychomotor surgical decision making model was constructed. Face and content validities of the model were verified by experts in surgery and decision making. CONCLUSIONS: Dynamic surgical decision making is a multi-faceted and intricate process. We have used HTA to map this process and we present a model in surgical decision making. By understanding the mechanisms and factors which influence this process we may use it for effective, focused surgical training. We aim to use and test our model also on open major complex surgery.

Constructing hierarchical task analysis in surgery.

BACKGROUND: Generic technical skills are required by a surgeon to perform a complete operation or procedure. They alone do not form a task or subtask but allow the surgeon to perform so. Specific technical skills are required to complete a task or subtask, which can be depicted by hierarchical task analysis (HTA). In this study we aim to demonstrate a reliable and valid method to construct a surgical HTA. METHODS: One hundred thirty video recordings of operations and procedures (30 laparoscopic cholecystectomies, 20 open inguinal hernia repairs, 20 saphenofemoral junction ligations, 20 upper GI and 40 lower GI endoscopies) from 37 different expert surgeons were assessed in view of constructing a HTA. Three research surgeons with more than eight years of postgraduate surgical experience assessed each operation or procedure blindly and independently and constructed a HTA. Each consultant surgeon assessed the HTA constructed by the researchers and modified it according to his/her own technical style. RESULTS: For tasks there was a 100% correlation between the researchers and individual expert surgeons. Mean interrater reliability for subtasks was k = 0.89 (range = 0.81-0.95), p < 0.05. Content and face validities of the HTA were confirmed by the expert surgeons. CONCLUSIONS: This study outlines a valid and reliable method of constructing a surgical task analysis and HTA for any operation or procedure, which could be used to assess and evaluate trainees' and expert surgeons' specific technical skills.

Development of assessing generic and specific technical skills in laparoscopic surgery.

BACKGROUND: Assessing live laparoscopic surgery using structured methodology is still in its infancy; however, it removes bias and subjectivity. We critique a new assessment tool for technical skills in laparoscopic surgery. METHODS: A hierarchical task analysis was done for laparoscopic cholecystectomy (LC), and a global assessment for generic and specific technical skills for LC was developed. Two experienced surgeons with >12 years of postgraduate experience assessed 50 full-length LC operations blindly and independently. RESULTS: Five consultant/attending and 4 registrar/resident surgeons were recruited. Interrater reliability was k = 0.86 and k = 0.84 (P < .05) for generic and specific technical skills, respectively. Mean time for consultants was 32 minutes (range 15 to 70) and for registrars was 53 minutes (range 20 to 90). Parametric Student t test analysis was significant for time between the 2 groups, P < .05. Nonparametric analysis of variance between the 2 groups for generic and specific technical skills was significant at P < .05. CONCLUSIONS: This assessment tool for live laparoscopic surgery may have face, content, concurrent, construct, and predictive validities for generic and specific technical skills. We aim to continue the study and expand assessment to other surgical techniques.

Technical and technological skills assessment in laparoscopic surgery.

OBJECTIVES: Surgical appraisal and revalidation are key components of good surgical practice and training. Assessing technical skills in a structured manner is still not widely used. Laparoscopic surgery also requires the surgeon to be competent in technological aspects of the operation. METHODS: Checklists for generic, specific technical, and technological skills for laparoscopic cholecystectomies were constructed. Two surgeons with >12 years postgraduate surgical experience assessed each operation blindly and independently on DVD. The technological skills were assessed in the operating room. RESULTS: One hundred operations were analyzed. Eight trainees and 10 consultant surgeons were recruited. No adverse events occurred due to technical or technological skills. Mean interrater reliability was kappa=0.88, P=<0.05. Construct validity for both technical and technological skills between trainee and consultant surgeons were significant, Mann-Whitney P=<0.05. CONCLUSIONS: Our study demonstrates that technical and technological skills can be measured to assess performance of laparoscopic surgeons. This technical and technological assessment tool for laparoscopic surgery seems to have face, content, concurrent, and construct validities and could be modified and applied to any laparoscopic operation. The tool has the possibility of being used in surgical training and appraisal. We aim to modify and apply this tool to advanced laparoscopic operations.

Laparoscopic extraperitoneal repair of Amyand's inguinal hernia.

Amyand's hernia (appendix in the sac of an inguinal hernia) although rare is a fairly well-recognized clinical entity. It is associated with an increased risk of developing appendicitis. Amyand's hernia can be repaired by open or laparoscopic methods. We present the case of a laparoscopic extraperitoneal repair with a potential hazard when repairing this type of hernia in this manner, and we review the literature on this condition.

Assessing the teaching of technical skills.

BACKGROUND: There is a lack of structured instruments to assess how technical skills are taught. We aimed to develop a practical assessment tool that is easy to use and will assess the teaching of technical skills. METHODS: A 5-point Likert global rating scale was constructed. An experienced surgeon independently assessed each surgery using the assessment tool. Trainees also used the assessment tool after the surgery. RESULTS: Forty-two surgeries were assessed: 26 open and 16 laparoscopic surgeries. Interrater reliability between the independent assessor and trainees was performed using a kappa coefficient of .77 and a P value of less than .05. CONCLUSIONS: Our study shows that our assessment instrument has a potential ability to assess any taught technical task. We will continue and expand the study in surgery, and we aim to expand it further to medical specialties (eg, internal medicine, and so forth) that also teach technical tasks (eg, chest drain insertion, and so forth).

Errors in surgery.

Making errors is part of normal human behaviour. However when errors have significant consequences or occur in high risk industries they become of paramount importance. There has been little research in why and how errors occur in the healthcare industry. Errors occur throughout healthcare, but in particular, surgery as a high risk speciality. Surgery is a dynamic speciality with a milieu of possible mishaps waiting to happen. So to understand and prevent errors in surgery we must explore this intricate multi-cogwheel process. This article will summarise the epidemiology of surgical errors, factors which influence them in the patient pathway, explain concepts and models of why errors occur, technical skill error assessment and possible strategies to prevent or reduce surgical errors. Practicing surgery in the new millennium will embrace new innovations, medications, technologies, equipment, operations, all which aim to improve the treatment and care of patients. However we must remember with this constant evolution in healthcare the error goalposts are forever moving, so we must be vigilant not to take our eye off the error ball.

Systems approaches to surgical quality and safety: from concept to measurement.

OBJECTIVE: This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. SUMMARY BACKGROUND DATA: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. METHODS: Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an "operation profile" to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.