Successful Separation of Conjoined Twins: The Contemporary Experience and Historic Review in Memphis.

Conjoined twins are a rare phenomenon with historically poor outcomes after separation. We present a review of 8 sets of conjoined twins operated on in Memphis, Tenn, from 1953-2016. Except for 1 set of twins, before 2010, all experienced at least 1 fatality either before, during, or as a result of separation. Since 2010, we have separated an additional 2 sets of conjoined twins with no mortality related to the separation, although 1 of the first twins had significant cardiac and respiratory abnormalities and died several years after the separation. Each set of twins presented many challenges in reconstruction; however, the use of tissue expansions in the 2 most recent sets of twins proved to be beneficial. Although improvements in imaging, surgical technology, and postoperative monitoring likely have contributed to the increased survival, previous experience and meticulous planning with a multidisciplinary approach may have been the most influential.

Does Wearable Medical Technology With Video Recording Capability Add Value to On-Call Surgical Evaluations?

Background Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol-which avoids transmission issues associated with real-time applications-for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass' HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation.

The effect of stress on learning in surgical skill acquisition.

BACKGROUND: An excessive level of stress and anxiety in medical education can have a negative impact on learning. In particular, the interaction between attending surgeons and trainees in the operating room could induce stress on trainees that is counterproductive, especially if the teaching style or feedback is unduly harsh or critical. AIM: To characterize the effects of stress resulting from attending-trainee interaction during surgical skill acquisition. METHODS: Forty medical students learned to perform the FLS pattern-cutting task for the first time in one of four scenarios. In the control condition, no mentor was present. In the three experimental conditions, participants were observed, encouraged, or criticized by an expert surgeon. RESULTS: Task performance, as well as physiological and subjective indicators of stress, were measured. Taking both speed and accuracy into account, participants who were criticized performed the worst on the task, and those who were encouraged performed best. Physiological and subjective measures indicated that the criticized participants experienced the highest level of stress and anxiety. CONCLUSION: Even though providing constructive criticism to trainees is inevitable during the course of teaching, an exceedingly critical and negative mentoring style by attending physicians could be detrimental to trainees' acquisition of surgical skills.

Face validation of the Virtual Electrosurgery Skill Trainer (VEST©).

BACKGROUND: Electrosurgery is a modality that is widely used in surgery, whose use has resulted in injuries, OR fires and even death. The SAGES has established the FUSE program to address the knowledge gap in the proper and safe usage of electrosurgical devices. Complementing it, we have developed the Virtual Electrosurgery Skill Trainer (VEST(©)), which is designed to train subjects in both cognitive and motor skills necessary to safely operate electrosurgical devices. The objective of this study is to asses the face validity of the VEST(©) simulator. METHODS: Sixty-three subjects were recruited at the 2014 SAGES Learning Center. They all completed the monopolar electrosurgery module on the VEST(©) simulator. At the end of the study, subjects assessed the face validity with questions that were scored on a 5-point Likert scale. RESULTS: The subjects were divided into two groups; FUSE experience (n = 15) and no FUSE experience (n = 48). The median score for both the groups was 4 or higher on all questions and 5 on questions on effectiveness of VEST(©) in aiding learning electrosurgery fundamentals. Questions on using the simulator in their own skills lab and recommending it to their peers also scored at 5. Mann-Whitney U test showed no significant difference (p > 0.05) indicating a general agreement. 46% of the respondents preferred VEST compared with 52% who preferred animal model and 2% preferred both for training in electrosurgery. CONCLUSION: This study demonstrated the face validity of the VEST(©) simulator. High scores showed that the simulator was visually realistic and reproduced lifelike tissue effects and the features were adequate enough to provide high realism. The self-learning instructional material was also found to be very useful in learning the fundamentals of electrosurgery. Adding more modules would increase the applicability of the VEST(©) simulator.

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer.

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES.

BACKGROUND: NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy. METHODS: Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps. RESULTS: At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy. CONCLUSION: As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

Effects of sleep hours and fatigue on performance in laparoscopic surgery simulators.

BACKGROUND: Studies on a virtual reality simulator have demonstrated that sleep-deprived residents make more errors. Work-hour restrictions were implemented, among other reasons, to ensure enough sleep time for residents. The objective of this study was to assess the effects of sleep time, perceived fatigue, and experience on surgical performance. We hypothesized that performance would decrease with less sleep and fatigue, and that experienced surgeons would perform better than less experienced surgeons despite sleep deprivation and fatigue. METHODS: Twenty-two surgical residents and attendings performed a peg transfer task on two simulators: the Fundamentals of Laparoscopic Skills (FLS) trainer and the Virtual Basic Laparoscopic Surgical Trainer (VBLaST©), a virtual version of the FLS. Participants also completed questionnaires to assess their fatigue level and recent sleep hours. Each subject performed ten trials on each simulator in a counterbalanced order. Performance was measured using the FLS normalized scores and analyzed using a multiple regression model. RESULTS: The multiple regression analysis showed that sleep hours and perceived fatigue were not covariates. No correlation was found between experience level and sleep hours or fatigue. Sleep hours and fatigue did not appear to affect performance. Expertise level was the only significant determinant of performance in both FLS and VBLaST©. CONCLUSIONS: Restricting resident work hours was expected to result in less fatigue and better clinical performance. In our study, peg transfer task performance was not affected by sleep hours. Experience level was a significant indicator of performance. Further examination of the complex relationship between sleep hour, fatigue, and clinical performance is needed to support the practice of work-hour restriction for surgical residents.

Posttraumatic stress disorder in maltreated youth: a review of contemporary research and thought.

Youths who have been maltreated often experience symptoms of posttraumatic stress disorder (PTSD), and this special population has received increased attention from researchers. Pathways toward maladaptive effects of maltreatment and PTSD are remarkably similar and reflect specific biological diatheses and psychological vulnerabilities that produce wide-ranging self-regulation deficits. Developmental models of effects of maltreatment and of PTSD are thus increasingly intertwined and have begun to inform specialized assessment and treatment strategies for this population. This review covers key aspects of posttraumatic stress disorder in maltreated youth, including epidemiology, symptomatology, outcome, and risk factors as well as assessment and treatment strategies and challenges for these youths.

Depression and ethnicity as intermediary variables among dissociation, trauma-related cognitions, and PTSD symptomatology in youths.

The study of childhood posttraumatic stress disorder (PTSD) has grown in recent years, and several variables have been closely linked to the etiology of this condition. Prominent examples include dissociation, trauma-related cognitions, and depression, but no empirically based model regarding these variables has been presented. We examined 90 adolescents housed in a state-run facility for youths who experienced maltreatment, violence, and/or other traumas. Utilizing psychometrically strong dependent measures, we identified a structural equation model with depression as a key mediating variable between (1) dissociation and trauma-related cognitions and (2) PTSD symptomatology. In addition, African American status was found to weaken this relationship, whereas multiracial status was found to strengthen this relationship. These results are discussed within the context of contemporary integrative theories regarding the developmental psychopathology of PTSD in youths.