Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures.

BACKGROUND: The critical view of safety (CVS) is poorly adopted in surgical practices, although it is recommended ubiquitously to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aimed to investigate whether performing a short intraoperative time-out can improve CVS implementation. STUDY DESIGN: In this before vs after study, surgeons performing LCs at an academic center were invited to use a 5-second long time-out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LC performed in the year before vs the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by 2 independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. RESULTS: Three hundred and forty-three of 381 LC performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9% vs 44.1% before vs after the 5-second rule, respectively; p < 0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2% vs 15.7%; p = 0.04), median time (hours:minutes:seconds) to clip the cystic duct or artery (00:17:26; interquartile range 00:11:48 to 00:28:35 vs 00:23:12; interquartile range 00:14:29 to 00:31:45 duration; p = 0.007), and the rate of postoperative CVS reporting (1.3% vs 28.8%; p < 0.001). Postoperative morbidity was comparable (1.8% vs 2.3%; p = 0.68). CONCLUSIONS: Performing a short intraoperative time-out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Comparison of surgeon gaze behaviour against objective skill assessment in laparoscopic cholecystectomy-a prospective cohort study.

BACKGROUND: Eye tracking technology may provide the basis of a novel, objective technical skill assessment in surgery. Past research has showed differences in the gaze patterns between expert and novice surgeons. The aim of this study was to investigate the relationship between gaze behaviors and technical skill during laparoscopic cholecystectomy as determined by objective assessment scores. METHODS: Gaze behaviors of surgeons performing laparoscopic cholecystectomies were mapped using wearable eye tracking apparatus. Two impartial surgeons retrospectively analyzed video footage of the procedure to perform Objective Structured Assessment of Technical Skill (OSATS) assessments. Primary endpoints were correlation between gaze behaviours (dwell time (%) and fixation frequency (count/s)) and OSATS scores. Dwell time was defined as the percentage of time spent fixating on particular visual areas of interest (AOI). Pearson's correlation coefficient was used to estimate the relationship between primary endpoints and AOIs. Statistical significance was set at p < 0.05. RESULTS: 13 procedures were analyzed. Throughout all operative segments, a negative correlation was present between operating theatre dwell time and OSATS scores (p < 0.05). During dissection of Calot's triangle, there was a strong positive correlation between laparoscopic screen dwell time and OSATS scoring [r = 0.655, p < 0.05]. Scrub nurse dwell time during dissection of Calot's triangle showed a strong negative correlation with OSATS scoring [r = -0.619, p < 0.05]. During dissection of gallbladder fossa, operating theatre fixation frequency negatively correlated against OSATS scores [r = -0.566, p < 0.05]. CONCLUSION: The results suggest a greater focus on significant visual stimuli alongside a lack of attention to non-essential stimuli during critical stages of the operative period is associated with greater technical skill. This aids the validation of eye tracking as an adjunct high-stakes technical skill assessment.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis.

BACKGROUND: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Reduced Port Laparoscopic Cholecystectomy: An Innovative, Cost-Effective Technique with Superior Cosmetic Outcomes.

INTRODUCTION: Patient demand for cosmetically superior surgical outcomes has driven minimally invasive technique development like single incision laparoscopic cholecystectomy (SILC). Implementation has been hindered by equipment factors, compromise of ergonomics, increased cost, and larger primary incision, leading to the associated risk of postoperative wound complications, incisional hernia, and fascial dehiscence. We present a method of reduced port laparoscopic cholecystectomy (RPLC), which utilises existing laparoscopic conventional equipment and an innovative MiniLap® grasper (Teleflex Incorporated, Wayne, Pennsylvania). The aim of the approach being enhanced cosmesis, cost equivalence with existing methods, and preservation of surgical ergonomics. MATERIALS AND METHODS: Twenty consecutive patients presenting to a single-surgeon practice with pathology requiring cholecystectomy and favourable body habitus were offered an RPLC procedure. Abdominal access was obtained via two laparoscopic working ports placed through a single incision within the umbilicus and with a 2.3mm port-less MiniLap® inserted via stab incision in the right upper quadrant utilised for retraction. Operative time, cost, cosmesis, postoperative pain, and patient demographics were compared with the standard four-port cholecystectomy. RESULTS: Twenty patients underwent RPLC with age ranging from 20 to 67 with a mean body mass index (BMI) of 31kg/m2. Mean operative time of 36.3 minutes was comparable to conventional multi-port laparoscopic cholecystectomy (LC). All operations were completed as RPLC, and no conversion to conventional four-port laparoscopic cholecystectomy was required. Gall bladder retraction with Teleflex grasper and an innovative swirling technique provides adequate exposure of the hepato-cystic triangle. Patient response regarding cosmetic outcome of the procedure was overwhelmingly positive. A single complication of the RPLC technique was documented-a superficial umbilical site wound infection, which was treated with oral antibiotics. Instrumental cost of the RPLC was $80 (AUD) greater than standard 4LP due to reduced port number but higher MiniLap® cost. CONCLUSION: The RPLC method utilises an ergonomically attractive technique with outcomes and a safety profile equal to the standard multi-port LC whilst minimizing the complications and prohibitive economic penalties of traditional SILC. A well-designed prospective randomised trial can provide more insight into the pros and cons of this innovative technique.

Meta-analysis of the cost-effectiveness of early versus delayed cholecystectomy for acute cholecystitis.

Background: Acute calculous cholecystitis (ACC) is a common disease across the world and is associated with significant socioeconomic costs. Although contemporary guidelines support the role of early laparoscopic cholecystectomy (ELC), there is significant variation among units adopting it as standard practice. There are many resource implications of providing a service whereby cholecystectomies for acute cholecystitis can be performed safely. Methods: Studies that incorporated an economic analysis comparing early with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were identified by means of a systematic review. A meta-analysis was performed on those cost evaluations. The quality of economic valuations contained therein was evaluated using the Quality of Health Economic Studies (QHES) analysis score. Results: Six studies containing cost analyses were included in the meta-analysis with 1128 patients. The median healthcare cost of ELC versus DLC was €4400 and €6004 respectively. Five studies had adequate data for pooled analysis. The standardized mean difference between ELC and DLC was -2·18 (95 per cent c.i. -3·86 to -0·51; P = 0·011; I 2 = 98·7 per cent) in favour of ELC. The median QHES score for the included studies was 52·17 (range 41-72), indicating overall poor-to-fair quality. Conclusion: Economic evaluations within clinical trials favour ELC for ACC. The limited number and poor quality of economic evaluations are noteworthy.

Targeting Value-Driven Quality Improvement for Laparoscopic Cholecystectomy in Michigan.

OBJECTIVE: The purpose of this study was to evaluate complete episode expenditures for laparoscopic cholecystectomy, a common and lower-risk operation, to characterize novel targets for value-based quality improvement. SUMMARY BACKGROUND DATA: Despite enthusiasm for improving the overall value of surgical care, most efforts have focused on high-risk inpatient surgery. METHODS: We identified 19,213 patients undergoing elective laparoscopic cholecystectomy from 2012 to 2015 using data from Medicare and a large private payer. We calculated price-standardized payments for the entire surgical episode of care and stratified patients by surgeon. We used linear regression to risk- and reliability-adjusted expenditures for patient characteristics, diagnoses, and the use of additional procedures. RESULTS: Fully adjusted total episode costs varied 2.4-fold across surgeons ($7922-$17,500). After grouping surgeons by adjusted total episode payments, each component of the total episode was more expensive for patients treated by the most expensive versus the least expensive quartile of surgeons. For example, payments for physician services were higher for the most expensive surgeons [$1932, 95% confidence interval (CI) $1844-$2021] compared to least expensive surgeons ($1592, 95% CI $1450-$1701, P < 0.01). Overall differences were driven by higher rates of complications (10% vs. 5%) and readmissions (14% vs. 8%), and lower rates of ambulatory procedures (77% vs. 56%) for surgeons with the highest versus lowest expenditures. Projections showed that a 10% increase ambulatory operations would yield $3.6 million in annual savings for beneficiaries. CONCLUSIONS: Episode payments for laparoscopic cholecystectomy vary widely across surgeons. Although improvements in several domains would reduce expenditures, efforts to expand ambulatory surgical practices may result in the largest savings to beneficiaries in Michigan.

High-resolution standardization reduces delay due to workflow disruptions in laparoscopic cholecystectomy.

BACKGROUND: Optimal resource utilization in high-cost environments like operating theatres is fundamental in today's cost constrained health care systems. Interruptions of the surgical workflow, i.e. microcomplications (MC), lead to prolonged procedure times and higher costs and can be indicative of surgical mistakes. Reducing MC can improve operating room efficiency and prevent intraoperative complications. We, therefore, aimed to evaluate the impact of a high-resolution standardized laparoscopic cholecystectomy protocol (HRSL) on operative time and intraoperative interruptions in a teaching hospital. METHODS: HRSL consisted of a detailed stepwise protocol for the procedure, supported by a teaching video, both to be reviewed as mandatory preparation by each team member before surgery. Audio-video records of laparoscopic cholecystectomies were reviewed regarding type, frequency and duration of MC before and after implementation of HRSL. RESULTS: Thirty-nine (20 control and 19 HRSL) audio-video records of laparoscopic cholecystectomies with a total duration of 51.36 h (28.92 pre 22.44 post) were reviewed. The majority of operations (86%) were performed by teams who had completed less than 10 procedures together previously. Communication-related interruptions and instrument changes accounted for the majority of MC. Median frequency and duration of MC were 95 events/h and 15.6 min/h, respectively, of surgery pre-intervention. With HRSL this was reduced to 76 events/h and 10.6 min/h of operating. In multivariable analysis, HRSL was an independent predictor for shorter delay and lower frequency of MC [percentage decrease 27% (95% CI 18-35%), resp. 30% (95% CI 19-40%)]. Procedure-related risk factors for the longer delay due to MC in multivariable analysis were less experience of the surgeon and intraoperative adhesiolysis. CONCLUSIONS: HRSL is effective in reducing delays due to MC in a teaching institution with limited team experience. These findings should be tested in larger potentially cluster-randomized controlled trials. The trial has been registered with clinicaltrials.gov: NCT03329859.

Variability in Case Durations for Common Surgical Procedures.

BACKGROUND: Under the Merit-based Incentive Payment System, physician payment will be adjusted using a composite performance score that has 4 components, one of which is resource use. The objective of this exploratory study is to quantify the facility-level variation in surgical case duration for common surgeries to examine the feasibility of using surgical case duration as a performance metric. METHODS: We used data from the National Anesthesia Clinical Outcomes Registry on 404,987 adult patients undergoing one of 6 general surgical or orthopedic procedures: laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram, knee arthroscopy, laminectomy, and total hip replacement. We constructed separate mixed-effects multivariable time-to-event models (survival analysis) for each of the 6 procedures to model surgical case duration. RESULTS: We identified performance outliers, based on surgical case duration, using 2013 data and then quantified the gap between high- and low-performance outliers using 2014 data. After adjusting for patient risk, patients undergoing surgery at high-performance facilities were between 54% and 79% more likely to exit the operating room (OR) per unit time compared to average-performing facilities, depending on the procedure. For example, patients undergoing a laparoscopic appendectomy at high-performance facilities were 68% more likely to exit the OR per unit time (hazard ratio, 1.68; 95% CI, 1.40-2.02; P < .001) compared to average-performing facilities. Patients undergoing a laparoscopic appendectomy at low-performance facilities were 41% less likely to exit the OR per unit time (hazard ratio, 0.59; 95% CI, 0.47-0.74; P < .001) compared to average-performing facilities. The adjusted median surgical case duration for patients undergoing laparoscopic appendectomy was 69 minutes at high-performance centers and 92 minutes at low-performance centers. Similar results were obtained for the other procedures. CONCLUSIONS: There was wide variation in surgery case duration for patients undergoing common general surgical and orthopedic surgeries. This variability in care delivery may represent an important opportunity to promote more efficient use of health care resources.

Picking apart surgical pick lists - Reducing variation to decrease surgical costs.

BACKGROUND: Average costs associated with common procedures can vary by surgeon without a corresponding variation in outcome or case complexity. METHODS: De-identified cost and equipment utilization data were collected from our hospital for elective laparoscopic cholecystectomy performed by 17 different surgeons over a 6-month period. A group of surgeons used this data to design a standardized equipment pick list that became optional (not mandated) for laparoscopic cholecystectomy. Cost and consumable surgical supply utilization data were collected for six months prior to and following the creation of the standardized pick-list. RESULTS: 280 elective laparoscopic cholecystectomies were performed during the study interval. In the 6 months after standardized pick list creation, the cost of disposable supplies utilized per case decreased by 32%. CONCLUSIONS: Surgical cost savings can be achieved with standardized procedure pick lists and attention to the cost of consumable surgical supplies.

Concerns of Quality and Safety in Public Domain Surgical Education Videos: An Assessment of the Critical View of Safety in Frequently Used Laparoscopic Cholecystectomy Videos.

BACKGROUND: Online videos are among the most common resources for case preparation. Using crowd sourcing, we evaluated the relationship between operative quality and viewing characteristics of online laparoscopic cholecystectomy videos. STUDY DESIGN: We edited 160 online videos of laparoscopic cholecystectomy to 60 seconds or less. Crowd workers (CW) rated videos using Global Objective Assessment of Laparoscopic Skills (GOALS), the critical view of safety (CVS) criteria, and assigned overall pass/fail ratings if CVS was achieved; linear mixed effects models derived average ratings. Views, likes, dislikes, subscribers, and country were recorded for subset analysis of YouTube videos. Spearman correlation coefficient (SCC) assessed correlation between performance measures. RESULTS: One video (0.06%) achieved a passing CVS score of ≥5; 23%, ≥4; 44%, ≥3; 79%, ≥2; and 100% ≥1. Pass/fail ratings correlated to CVS, SCC 0.95 (p < 0.001) and to GOALS, SCC 0.79 (p < 0.001). YouTube videos (n = 139) with higher views, likes, or subscribers did not correlate with better quality. The average CVS and GOALS scores were no different for videos with >20,000 views (22%) compared with those with <20,000 (78%). CONCLUSIONS: There is an incredibly low frequency of CVS and average GOALS technical performance in frequently used online surgical videos of LC. Favorable characteristics, such as number of views or likes, do not translate to higher quality.

Evaluation of crowd-sourced assessment of the critical view of safety in laparoscopic cholecystectomy.

BACKGROUND: Faculty experts (FE) and crowd workers (CW) can assess technical skill, but assessment of operative technique has not been explored. We sought to evaluate if CW could be taught to assess completion of the critical view of safety (CVS) in laparoscopic cholecystectomy. METHODS: We prepared 160 blinded, surgical videos of laparoscopic cholecystectomy from public domain websites. Videos were edited to ≤60 s, ending when a structure was cut/clipped. CW analyzed videos using Global Objective Assessment of Laparoscopic Skills (GOALS) and CVS criteria assessment tools after watching an instructional tutorial. Ten videos were randomly selected from each performance quartile based on GOALS. Five FE rated the 40 videos using GOALS and CVS. Linear mixed effects models derived average CW and FE ratings for GOALS and CVS for each video. Spearman correlation coefficients (SCC) were used to assess the degree of correlation between performance measures. Satisfactory completion of the CVS was defined as scoring an average CVS ≥ 5. Videos with an average GOALS ≥ 15 were considered top technical performers. RESULTS: A high degree of correlation was seen between all performance measures: CVS ratings between CW and FE, SCC 0.89 (p < 0.001); GOALS and CVS ratings SCC 0.77 (p < 0.001) for CW, and SCC 0.71 (p < 0.001) for FE. Sixteen videos were assigned top technical performer ratings by both CW and FE but the average CVS was inadequate (3.8 and 3.6, respectively), and the percentage of satisfactory CVS ≥ 5 was 12.5%. CONCLUSIONS: A high degree of correlation was found between CW and FE in assessment of the CVS. However, in this video analysis, high technical performers did not achieve a complete CVS in most cases. Educating CW to assess operative technique for the identification of low or average performers is feasible and may broaden the application of this assessment and feedback tool.

An Ambulatory Surgery Perioperative Surgical Home in Kaiser Permanente Settings: Practice and Outcomes.

BACKGROUND: The aim of this study is to describe the design, implementation, and associated outcome changes of a Perioperative Surgical Home (PSH) for patients undergoing ambulatory laparoscopic cholecystectomy in a Kaiser Permanente practice model. METHODS: A multidisciplinary planning committee of 15 individuals developed and implemented a new PSH program. A total of 878 subjects were included in the preimplementation period (T-fast), and 1082 patients were included in the postimplementation period (PSH) based on the date of their surgery. The primary goal of this report was to assess the changes in patient outcomes associated with this new PSH implementation on variables such as total length of stay and unplanned hospital admission (UHA). RESULTS: Patients assigned to the PSH model had a significantly shorter mean length of stay compared with patients in the T-fast group (162 ± 308 vs 369 ± 790 minutes, P = .00005). UHA was significantly higher in the T-fast group as compared with the PSH group (8.5% [95% CI 6.6-10.4] vs 1.7% [0.9-2.5], P < .00005). There was no difference in the 7 days readmission rates between patients managed in the T-fast track and the PSH track (5.4% [3.8-7.0] vs 5.0% [3.6-6.3], P = .066). CONCLUSIONS: Introduction of the PSH into a Kaiser Permanente model of care was associated with a simultaneous decrease of length of stay and UHA for laparoscopic cholecystectomy patients.

Validity, reliability and support for implementation of independence-scaled procedural assessment in laparoscopic surgery.

BACKGROUND: There is no widely used method to evaluate procedure-specific laparoscopic skills. The first aim of this study was to develop a procedure-based assessment method. The second aim was to compare its validity, reliability and feasibility with currently available global rating scales (GRSs). METHODS: An independence-scaled procedural assessment was created by linking the procedural key steps of the laparoscopic cholecystectomy to an independence scale. Subtitled and blinded videos of a novice, an intermediate and an almost competent trainee, were evaluated with GRSs (OSATS and GOALS) and the independence-scaled procedural assessment by seven surgeons, three senior trainees and six scrub nurses. Participants received a short introduction to the GRSs and independence-scaled procedural assessment before assessment. The validity was estimated with the Friedman and Wilcoxon test and the reliability with the intra-class correlation coefficient (ICC). A questionnaire was used to evaluate user opinion. RESULTS: Independence-scaled procedural assessment and GRS scores improved significantly with surgical experience (OSATS p = 0.001, GOALS p < 0.001, independence-scaled procedural assessment p < 0.001). The ICCs of the OSATS, GOALS and independence-scaled procedural assessment were 0.78, 0.74 and 0.84, respectively, among surgeons. The ICCs increased when the ratings of scrub nurses were added to those of the surgeons. The independence-scaled procedural assessment was not considered more of an administrative burden than the GRSs (p = 0.692). DISCUSSION/CONCLUSION: A procedural assessment created by combining procedural key steps to an independence scale is a valid, reliable and acceptable assessment instrument in surgery. In contrast to the GRSs, the reliability of the independence-scaled procedural assessment exceeded the threshold of 0.8, indicating that it can also be used for summative assessment. It furthermore seems that scrub nurses can assess the operative competence of surgical trainees.

Validation and reliability of Global Operative Assessment of Laparoscopic Skills for surgical residents and consultants.

OBJECTIVE: To institute and validate the Global Assessment of Laparoscopic Surgery score as a measure of intraoperative performance. METHODS: The observational study was conducted at the Services Hospital, Lahore, and the National Hospital and Medical Centre, Lahore, from August 1, 2013, to February 28, 2014, and comprised Residents, Senior Registrars and Consultants who were divided into 3 groups. The Junior group comprised Residents from years 1, 2 and3; the Intermediate group had year 4 Residents and Senior Registrars; and the Senior group included Consultants. All participants had their evaluation using Global Assessment of Laparoscopic Surgeryscore while performing dissection of gall bladder from the liver bed during laparoscopic cholecystectomy. SPSS 20 was used for statistical analysis. RESULTS: Of the 24 subjects in the study, 12(50%) were Residents, 6(25%) Senior Registrars and 6(25%) Consultants. The mean score for Junior group was 7.64±0.988, for Intermediate group 16.25±2.602 and for Senior group 22.83±1.169The score was highly reliable with intra-class coefficient 0.96, and internal consistency was excellent with Cronbach's Alpha 0.981. CONCLUSIONS: Global Assessment of Laparoscopic Surgery was found to be a valid and reliable measure of intraoperative laparoscopic skills.

A systematic review of performance assessment tools for laparoscopic cholecystectomy.

BACKGROUND: Multiple tools are available to assess clinical performance of laparoscopic cholecystectomy (LC), but there are no guidelines on how best to implement and interpret them in educational settings. The purpose of this systematic review was to identify and critically appraise LC assessment tools and their measurement properties, in order to make recommendations for their implementation in surgical training. METHODS: A systematic search (1989-2013) was conducted in MEDLINE, Embase, Scopus, Cochrane, and grey literature sources. Evidence for validity (content, response process, internal structure, relations to other variables, and consequences) and the conditions in which the evidence was obtained were evaluated. RESULTS: A total of 54 articles were included for qualitative synthesis. Fifteen technical skills and two non-technical skills assessment tools were identified. The 17 tools were used for either: recorded procedures (nine tools, 60%), direct observation (five tools, 30%), or both (three tools, 18%). Fourteen (82%) tools reported inter-rater reliability and one reported a Generalizability Theory coefficient. Nine (53%) had evidence for validity based on clinical experience and 11 (65%) compared scores to other assessments. Consequences of scores, educational impact, applications to residency training, and how raters were trained were not clearly reported. No studies mentioned cost. CONCLUSIONS: The most commonly reported validity evidence was inter-rater reliability and relationships to other known variables. Consequences of assessments and rater training were not clearly reported. These data and the evidence for validity should be taken into consideration when deciding how to select and implement a tool to assess performance of LC, and especially how to interpret the results.

Cost variation in a laparoscopic cholecystectomy and the association with outcomes across a single health system: implications for standardization and improved resource utilization.

BACKGROUND: Payers and regulatory bodies are increasingly placing emphasis on cost containment, quality/outcome measurement and transparent reporting. Significant cost variation occurs in many operative procedures without a clear relationship with outcomes. Clear cost-benefit associations will be necessary to justify expenditures in the era of bundled payment structures. METHODS: All laparoscopic cholecystectomies (LCCKs) performed within a single health system over a 1-year period were analysed for operating room (OR) supply cost. The cost was correlated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcomes. RESULTS: From July 2013 to June 2014, 2178 LCCKs were performed by 55 surgeons at seven hospitals. The median case OR supply cost was $513 ± 156. There was variation in cost between individual surgeons and within an individual surgeon's practice. There was no correlation between cost and ACS NSQIP outcomes. The majority of cost variation was explained by selection of trocar and clip applier constructs. CONCLUSIONS: Significant case OR cost variation is present in LCCK across a single health system, and there is no clear association between increased cost and NSQIP outcomes. Placed within the larger context of overall cost, the opportunity exists for improved resource utilization with no obvious risk for a reduction in the quality of care.

Advanced laparoscopic fellowship training decreases conversion rates during laparoscopic cholecystectomy for acute biliary diseases: a retrospective cohort study.

INTRODUCTION: Acute biliary pathology is a risk factor for conversion to open surgery and increased surgical morbidity during laparoscopic cholecystectomy (LC). The purpose of our study was to examine the impact of an advanced laparoscopic fellowship-trained surgeon on risks of conversion, surgical morbidity, and postoperative complications in this patient population. METHODS: Of 1382 patients who underwent an LC from January 2008 to August 2011, 592 patients were diagnosed with an acute biliary process and were included in the study. Patients were divided into two groups; those operated on by an advanced laparoscopic fellowship-trained surgeon (N=237), and those operated on by a non-laparoscopic fellowship-trained surgeon (N=355). The primary end-points were conversion rates and surgical morbidity. The secondary end-point was operative time. RESULTS: Fellowship-trained surgeons were more likely to perform IOC (57%) versus non-fellowship trained surgeons (20%) (p<0.0001). The conversion rate for the fellowship-trained group was significantly lower than for the non-fellowship trained group (1.7% vs 8.5%, p=0.0004). The intraoperative and postoperative complication rates for the fellowship-trained group were not significantly different. The operative time was slightly longer in the non-fellowship trained group compared to the fellowship-trained group (104 min vs 111 min, p=0.04). DISCUSSION: Our data demonstrate that advanced laparoscopic fellowship training decreases conversion rates of laparoscopic cholecystectomy for acute biliary pathology. Moreover, given the lower conversion rates, patients may have experienced shorter hospitalizations. CONCLUSIONS: Formal advanced laparoscopic fellowship training may decrease length of stay among patients presenting with acute biliary pathology who undergo laparoscopic cholecystectomy.

Assessment of surgery residents' operative skills in the operating theater using a modified Objective Structured Assessment of Technical Skills (OSATS): a prospective multicenter study.

BACKGROUND: With the implementation of competency-based curricula, Objective Structured Assessment of Technical Skills (OSATS) increasingly is being used for the assessment of operative skills. Although evidence for its usefulness has been demonstrated in experimental study designs, data supporting OSATS application in the operating room are limited. This study evaluates the validity and reliability of the OSATS instrument to assess the operative skills of surgery residents in the operating theater. METHODS: Twenty-four residents were recruited from seven hospitals within a general surgical training region and classified equally into three groups according to postgraduate training year (PGY). Each resident had to perform five different types of operations. Surgical performance was measured using a modified OSATS consisting of three scales: Global Rating Scale, Overall Performance Scale, and Alphabetic Summary Scale. Validity and reliability metrics included construct validity (Kruskal-Wallis test) and internal consistency reliability (Cronbach's α coefficient). Spearman's correlation coefficients were calculated to determine correlations between the different scales. RESULTS: Eighteen residents (PGY 1-2 [n = 7]; PGY 3-4 [n = 8]; PGY 5-6 [n = 3]) performed 249 operations. Comparisons of the performance scores revealed that evidence for construct validity depended on the difficulty level of the selected procedures. For individual operations, internal consistency reliability of the Global Rating Scale ranged from 0.93 to 0.95. Scores on the different scales correlated strongly (r = 0.62-0.76, P < .001). CONCLUSION: Assessment of operative skills in the operating theater using this modified OSATS instrument has the potential to establish learning curves, allowing adequate monitoring of residents' progress in achieving operative competence. The Alphabetic Summary Scale seems to be of additional value. Use of the Overall Performance Scale should be reconsidered.

Variations in procedure time based on surgery resident postgraduate year level.

BACKGROUND: With increasing scrutiny being placed on the allocation of health care dollars, data supporting the increased resources used to teach residents in the operating room (OR) are lacking. METHODS: All cases of patients undergoing laparoscopic cholecystectomies (LCs) and pancreaticoduodenectomies (PDs) from July 1, 2006 to July 1, 2011 were analyzed. Procedures were excluded based on the following: more than one resident listed in the operative report, with the exception of interns; LC requiring cholangiogram or conversion to an open procedure; or if a PD required additional procedures. Multiple linear regression was used to evaluate the association between procedure time and postgraduate year (PGY), adjusting for patient age and estimated blood loss. RESULTS: A total of 236 PDs and 357 LCs were included in the study. For LCs, after multiple linear regression, the association between procedure time and resident PGY was marginally significant (P = 0.0519) and suggested an inverse relationship; for every increase in resident PGY, there was a 2.66-min decrease in OR time. Based on our institution's figure of $18.13/min of OR time, the cost difference between PGYs 1 and 5 performing a LC would be $192.90 per case. For PDs, however, the association between procedure time and resident PGY was not significant. CONCLUSIONS: Junior residents likely prolong procedure times for more basic procedures such as LC but not for more complex procedures such as PD.

A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study.

OBJECTIVE: This study evaluated operative performance rating (OPR) characteristics and measurement conditions necessary for reliable and valid operative performance (OP) assessment. BACKGROUND: Operative performance is a signature surgical-practice characteristic that is not measured systematically and specifically during residency training. METHODS: Expert surgeon raters from multiple institutions, blinded to resident characteristics, independently evaluated 8 open and laparoscopic OP recordings immediately after observation. RESULTS: A plurality of raters agreed on operative performance ratings (OPRs) for all performances. Using 10 judges adjusted for rater idiosyncrasies. Interrater agreement was similar for procedure-specific and general items. Higher post graduate year (PGY) residents received higher OPRs. Supervising-surgeon ratings averaged 0.51 points (1.2 standard deviations) above expert ratings for the same performances. CONCLUSIONS: OPRs have measurement properties (reliability, validity) similar to those of other well-developed performance assessments (Mini-CEX [clinical evaluation exercise], standardized patient examinations) when ratings occur immediately after observation. OPRs by blinded expert judges reflect the level of resident training and are practically significant differences as the average rating for PGY 4 residents corresponded to a "Good" performance whereas those for PGY 5 residents corresponded to a "Very Good" performance. Supervising surgeon ratings are higher than expert judge ratings reflecting the effect of interpersonal factors on supervising surgeon ratings. Use of local and national norms for interpretation of OPRs would adjust for these interpersonal factors. The OPR system provides a practical means for measuring operative performance, which is a signature characteristic of surgical practice.