Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

BACKGROUND: Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module. METHODS: A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared. RESULTS: Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366 min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324 min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632 cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7 cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations. CONCLUSION: Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy.

BACKGROUND: Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution. METHODS: Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded. RESULTS: There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006). CONCLUSIONS: Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.

Educating surgeons may allow for reduced intraoperative costs for inguinal herniorrhaphy.

BACKGROUND: Our aim was to determine the impact of surgeon education regarding disposable supply costs to reduce intraoperative costs for a common procedure such as inguinal hernia repair. STUDY DESIGN: At the end of the 2013 fiscal year (FY 13), surgeons in our department were provided with information about the cost of disposable equipment and implants used in common general surgery operations. Surgeons who historically had lower supply costs demonstrated individual techniques to their colleagues. No financial incentive or punitive measures were used to encourage behavior change. Surgical supply costs for laparoscopic and open inguinal hernia repair in FY13 were then compared with costs during fiscal year 2014 (FY14) using Mann-Whitney U tests. RESULTS: The average cost of laparoscopic inguinal hernia repairs decreased from an average $1,088±473 (±SD) in FY13 (n=258) to $860±441 (n=274) in FY14 after surgeon education, representing a 21.0% reduction in intraoperative costs (p<0.001). The most impactful adjustments to reduce costs included selective use of mesh fixation devices (22.9%) and balloon dissecting trocars (27.6%), reduction in use of disposable scissors (13.8%), and reduction in use of disposable clip appliers (3.7%). Open inguinal hernia costs were reduced from an average (±SD) of $315±$253 in FY13 (n=366) to $288±$130 in FY14 (n=286), an 8.6% reduction in cost (p<0.01). In these cases, both avoiding the use of fixation devices and using less expensive mesh implants were identified as significant factors. CONCLUSIONS: Surgeon education and empowerment may significantly reduce the cost of disposable equipment in laparoscopic and open inguinal hernia repair. This simple educational technique could prove financially beneficial throughout various procedures and disciplines.

Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a regional health system's experience.

BACKGROUND: Surgeons play a crucial role in the cost efficiency of the operating room through total operative time, use of supplies, and patient outcomes. This study aimed to examine the effect of surgeon education on disposable supply usage during laparoscopic cholecystectomy. METHODS: Surgeons were educated about the cost of disposable equipments without incentives for achieved cost reductions. Surgical supply costs for laparoscopic cholecystectomy in fiscal year (FY) 2013 were compared with FY 2014. RESULTS: The average disposable supply cost per laparoscopic cholecystectomy was reduced from $589 (n = 586) in FY 2013 to $531 (n = 428) in FY 2014, representing a 10% reduction in supply costs (P < .001). Adjustments included reduction in the use of expensive fascial closure devices, clip appliers, suction irrigators, and specimen retrieval bags. CONCLUSIONS: Disposable equipment cost for laparoscopic cholecystectomy can be reduced by surgeon education. These techniques can likely be used to reduce costs in an array of specialties and procedures.

Single-incision surgery has higher cost with equivalent pain and quality-of-life scores compared with multiple-incision laparoscopic cholecystectomy: a prospective randomized blinded comparison.

BACKGROUND: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision (SI) to multi-incision (MI) laparoscopic cholecystectomy. STUDY DESIGN: After obtaining IRB approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multihospital, multisurgeon trial. Consenting patients were computer randomized into either a transumbilical SI or standard MI group; patient data were then entered into a prospective database. RESULTS: We report 79 patients that were prospectively enrolled and analyzed. Total hospital charges were found to be significantly different between SI and MI groups (MI $15,717 ± $14,231 vs SI $17,817 ± $5,358; p < 0.0001). Broken down further, the following subcharges were found to also be significant: operating room charges (MI $4,445 ± $1,078 vs SI $5,358 ± 893; p < 0.0001); medical/surgical supplies (MI $3,312 ± $6,526 vs SI $5,102 ± $1,529; p < 0.0001); and anesthesia costs (MI $579 ± $7,616 vs SI $820 ± $23,957; p < 0.0001). A validated survey (ie, Surgical Outcomes Measurement System) was used to evaluate various patient quality-of-life parameters at set visits after surgery; scores were statistically equivalent for fatigue, physical function, and satisfaction with results. No difference was found between visual analogue scale scores or inpatient and outpatient pain-medication use. CONCLUSIONS: We show SI surgery to have higher costs than MI surgery with equivalent quality-of-life scores, pain analogue scores, and pain-medication use.