Coaching to enhance qualified surgeons' non-technical skills: a systematic review.

INTRODUCTION: The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons. METHODS: A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI). RESULTS: Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study. CONCLUSION: Surgical coaching of qualified surgeons' NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.

Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study.

BACKGROUND: Laparoscopic surgery causes specific post-operative discomfort and intraoperative cardiovascular, pulmonary, and splanchnic changes. The CO2 pneumoperitoneum-related intra-abdominal pressure (IAP) remains one of the main drivers of these changes. We investigated the influence of deep neuromuscular blockade (NMB) on IAP and surgical conditions. METHODS: This is an open prospective single-subject design study in 20 patients (14 female/6 male) undergoing laparoscopic cholecystectomy. Inclusion criteria were 18 years or older, and American Society of Anesthesiologists classification 1 to 3. Under a standardised anaesthesia, lowest IAP providing adequate surgical conditions was assessed without NMB and with deep NMB [post-tetanic count (PTC)<2] with rocuronium. The differences between IAP allowing for an adequate surgical field before and after administration of rocuronium were determined, as were effects of patient gender, age, and body mass index. RESULTS: Mean IAP without NMB was 12.75 (standard deviation 4.49) mmHg. Immediately after achieving a deep NMB, this was 7.20 (2.51). This pressure difference of 5.55 mmHg (5.08, P<0.001) dropped to 3.00 mmHg (4.30, P<0.01) after 15 min. Higher IAP differences were found in women compared with men. A modest inverse relationship was found between pressure difference and age. CONCLUSIONS: We found an almost 25% lower IAP after a deep NMB compared with no block in laparoscopic cholecystectomy. Younger and female patients appear to benefit more from deep neuromuscular blockade to reduce IAP.

Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers.

BACKGROUND: Portal-systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non-cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods. METHODS: Literature up to 2011 was reviewed for adult patients with proven congenital or acquired PSSs. Only PSSs in normal livers were analysed for the methods of diagnosis. Eligible studies were identified by searching relevant databases, including PubMed, Embase, MEDLINE and the Cochrane Library. The selection of eligible articles was carried out using predefined inclusion criteria (adult, non-surgical PSS) and a set of search terms that were established before the articles were identified. RESULTS: Eighty studies were included describing 112 patients with congenital or acquired PSSs. The majority were diagnosed incidentally using Doppler ultrasound imaging and CT. CONCLUSION: Congenital and acquired PSSs are rare. They are usually clinically asymptomatic and discovered incidentally by radiological techniques. They may be clinically relevant owing to drug, tumour cell, metabolic and pathogen shunting.

Pancreaticoduodenectomy: outcomes in a low-volume, specialised Hepato Pancreato Biliary unit.

BACKGROUND: This study was designed to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume specialised Hepato Pancreato Biliary (HPB) unit. Volume outcome analyses show significantly better results for patients undergoing PD at high-volume centres (Begg et al. JAMA 280:1747-1751, 1998; Finlayson et al. Arch Surg 138:721-725, 2003; Birkmeyer et al. N Engl J Med 346:1128-1137, 2002; Gouma et al. Ann Surg 232:786-795, 2000). Centralisation of PD seems to be the logical conclusion to be drawn from these results. In countries like Australia with a small and widely dispersed population, centralisation may not be always feasible. Alternative strategy would be to have similar systems in place to those in high-volume centres to achieve similar results at low-volume centres. Many Australian tertiary care centres perform low to medium volumes of PD (Chen et al. HPB 12:101-108, 2010; Kwok et al. ANZ J Surg 80:605-608, 2010; Barnett and Collier ANZ J Surg 76:563-568, 2006; Samra et al. Hepatobiliary Pancreat Dis Int 10:415-421, 2011). Most of these have a specialised HPB unit, accredited by the Australia and New Zealand Hepatic pancreatic and biliary association (ANZHPBA), as training units for post fellowship training in HPB surgery. It is imperative to perform outcome-based analyses in these units to ensure safety and high quality of care. METHODS: Retrospective analysis of database for periampullary carcinoma (1998 till date) was performed in an ANZHPBA accredited HPB unit based at a tertiary care teaching hospital in South Australia. Because age older than 74 years is shown to be a predictive marker of increased morbidity and mortality after a PD, we analysed the outcomes in this subset of patients separately. RESULTS: Fifty-three patients underwent PD in 14 years. Overall mortality was 3.8 %. The last in hospital mortality was in 1999. The morbidity rates and the oncologic outcomes were similar to those in high-volume units. CONCLUSIONS: PD can be safely performed in a low-volume specialised unit at centres where the amenities and processes at high-volume centres can be replicated.

Is YouTube™ a good source of information for patients to understand laparoscopic fundoplication?

INTRODUCTION: Gastro-oesophageal reflux disease affects 10-20% of the population, and laparoscopic fundoplication is one management option. As the most frequently accessed video-sharing website, YouTube has become a popular source of information for patients. This study conducted a cross-sectional analysis of the quality and demographics of patient education videos available on YouTube for laparoscopic fundoplication. METHODS: Three searches were performed on YouTube using the phrases 'laparoscopic fundoplication', 'heartburn surgery' and 'reflux operation'. The Health on The Net (HON) code, DISCERN and Journal of the American Medical Association (JAMA) systems were used to score the first 75 results from each query. Information about each video was collected, including number of views, time since posting, number of comments and the author of the video. Relationships between these variables and video quality were investigated. RESULTS: The median number of views was 3,793. The most common author category was videos produced by surgeons. Overall the quality was poor, mean HON score was 2.5/8, mean DISCERN score was 29.3/80 and mean JAMA score was 1.5/4. Surgeon-authored videos scored higher when scored using the HON and JAMA systems. Videos of longer duration scored higher using all three scoring systems. No other factors were found to be associated with video quality. CONCLUSION: The quality of information in YouTube videos on laparoscopic fundoplication is unreliable. Doctors should be aware of this and caution their patients of YouTube's limitations. Further research is needed to develop validated scoring systems for evaluating the quality of patient education videos.

Isolated non-hepatic metastasis from upper gastrointestinal adenocarcinoma: A case for surgical resection.

INTRODUCTION: Upper Gastrointestinal Tract (UGIT) malignancy is an increasing problem in western society and its prognosis is generally poor. The prognosis dims even further with the presence of loco regional recurrences or distant metastasis. This article looks at the feasibility and potential benefit from resection of non-hepatic, non-nodal metastases and recurrences. PRESENTATION OF CASE: Case 1. A 72-year-old male who underwent total gastrectomy for a gastric adenocarcinoma presented with a splenic mass 40 months later and underwent a splenectomy. He is disease free at 30 months post-metastectomy. Case 2. A 54-year-old male with oesophagogastric junctional adenocarcinoma, underwent an Ivor-Lewis oesophagectomy. He developed a distal pancreatic mass at 24 months follow-up and underwent distal pancreatectomy and splenectomy. He is disease free at 12 months post-metastectomy. Case 3. A 75-year-old male underwent subtotal gastrectomy for lesser curvature adenocarcinoma. At 42 months follow-up, he developed solitary abdominal wall recurrence. This was locally resected with clear margins. After 12 months, he developed another full thickness abdominal wall recurrence with involvement of the hepatic flexure. Enbloc resection including right hemicolectomy was performed and he is disease free at 3 months. DISCUSSION: There is very scarce literature on resection of non-hepatic, non-nodal recurrences/distant metastasis in oesophagogastric cancers. Based on these cases, a surgical resection in selected cases may provide prolonged survival with good quality of life. CONCLUSION: Resection for isolated recurrences and metachronous metastasis from UGIT cancers may be worthwhile, especially if patients have minimal co-morbidities.

Technical note: facilitating laparoscopic liver biopsy by the use of a single-handed disposable core biopsy needle.

Despite the use of advanced radiological investigations, some liver lesions cannot be definitely diagnosed without a biopsy and histological examination. Laparoscopic Tru-Cut biopsy of the liver lesion is the preferred approach to achieve a good sample for histology. The mechanism of a Tru-Cut biopsy needle needs the use of both hands to load and fire the needle. This restricts the ability of the surgeon to direct the needle into the lesion utilising the laparoscopic ultrasound probe. We report a technique of laparoscopic liver biopsy using a disposable core biopsy instrument (BARD (R) disposable core biopsy needle) that can be used single-handedly. The needle can be positioned with laparoscopic graspers in order to reach posterior and superior lesions. This technique can easily be used in conjunction with laparoscopic ultrasound.

[Hooked roof cup in revision of difficult loose hip prosthesis cups. Results after a minimum of 10 years]. / Die Hakendachschale in der Revision schwieriger gelockerter Hüftprothesenpfannen. Resultate nach mindestens 10 Jahren.

The long-term results of acetabular revision after total hip arthroplasty (THA) with the use of a reinforcement ring with hook were evaluated. The study included 57 cases of surgery dating back 10 years or more. Of a total of 54 patients (57 operated hips), 18 patients (19 hips) died during the 10-year period and 2 patients (2 hips) were completely lost to follow-up. At the time of the revision surgery, the mean age of the remaining 34 patients (36 hips) was 62.5 years (range: 47-80). A THA revision was done in 25 cases and an acetabular revision only in 11 cases. The most common acetabular defect was a combined segmental and cavitary defect (n = 19), and in three cases there was pelvic discontinuity. Autologous or homologous cancellous bone grafts were used to fill acetabular cavities in 17 hip joints. Structured bone grafts, predominantly homologous bone, were used in ten cases for acetabular reconstruction. At a mean follow-up of 11.4 years (range: 10-14.5) three hip joints (8%) had undergone further revision. The revisions were done for aseptic loosening of the acetabular component in two cases and a septic loosening of both components in one case. Three further cases (8%) revealed signs of acetabular loosening. Two of these three patients were symptomatic but refused further revision surgery. In the 33 unrevised hip joints, a good or excellent clinical result with a d'Aubingé score of more than 14 points was found in 30 cases (92%). Osseous acetabular reconstruction with the use of a reinforcement ring leads to favorable results compared to other techniques. In the authors' opinion, this technique is preferable to those using oversized cups without osseous reconstruction of the acetabulum.