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PURPOSE: Laparoscopic colorectal resection (LC) is associated with known recovery benefits and earlier discharge when compared to open colorectal resection (OC). Whether earlier discharge leads to a paradoxical increase in readmission has not been well characterized. The aim of this study is to compare the risk of readmission after the two procedures in a large, nationally representative sample. METHODS: Patients who underwent colorectal resection in 2011 were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. LC and OC patients were compared for patient factors, complications, and readmission rates. A multivariable analysis controlling for significant factors was performed to evaluate factors associated with readmission. RESULTS: Of 30,428 patients who underwent colorectal resection, 40.2% underwent LC. Length of stay (LOS) after LC was shorter than after OC (5.7 vs. 9.7 days, p < 0.001). LC was associated with a significantly lower rate of surgical site infections (SSI), bleeding, reoperation, 30-day mortality, and complications. Risk of readmission was greater for patients undergoing proctectomy than colectomy (12.7 vs. 10.6 %, p < 0.001), but was lower after laparoscopic than open for both procedures after controlling for confounding factors. Obesity, DM, operating time ≥180 min, steroid use, and ASA class 3-5 were found to be associated with readmission. CONCLUSION: Despite its technical complexity, LC can be performed without concerns for increased complications or readmission. The shorter length of stay and the lower risk of readmissions underline the true benefits of the laparoscopic approach for colorectal resection.
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Colectomía/efectos adversos , Colectomía/métodos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Readmisión del Paciente , Anciano , Colectomía/mortalidad , Enfermedades del Colon/cirugía , Femenino , Humanos , Laparoscopía/mortalidad , Masculino , Hemorragia Posoperatoria/etiología , Enfermedades del Recto/cirugía , Análisis de Regresión , Factores de Riesgo , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/etiologíaRESUMEN
BACKGROUND: Surgical site infection (SSI) after cardiac surgery (CS) is a serious complication that increases hospital length of stay (LOS), has a substantial financial impact, and increases mortality. The study described here was done to evaluate the effect of a program to reduce SSI after CS. METHODS: In January 2007, a multi-disciplinary CS infection-prevention team developed guidelines and implemented bundled tactics for reducing SSI. Data for all patients who underwent CS from 2006-2008 were used to determine whether there was: 1) A difference in the incidence of SSI in white patients and those belonging to minority groups; 2) a reduction in SSI after intervention; and 3) a statistically significant difference in the incidence of SSI in the third quarter of each year as compared with the other quarters of the year. RESULTS: Of 3,418 patients who underwent CS; 1,125 (32.9%) were members of minority groups and 2,293 (67.1%) were white. Eighty (2.3%) patients developed SSI. There was no significant difference in the incidence of SSI in non-Hispanic white patients and all others (2.1% vs. 2.8%, p=0. 42). The incidence of SSI decreased significantly from 2006 (3.0%) to 2007 (2.5%) and 2008 (1.4%), (p=0.03). Surgical site infection occurred more often in the third quarter of each of the years of the study than in other quarters of each year (3.3 vs. 2.0%, p=0.038). CONCLUSIONS: Implementation of a program to reduce SSI after CS was associated with a lower incidence of SSI across all racial and ethnic groups and over time, but was not associated with a lower incidence of SSI in the third quarter of each year than in the other quarters.
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Control de Infecciones/métodos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Cirugía Torácica , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
BACKGROUND: The acquisition of technical skills is one of the fundamental goals of postgraduate surgical training; however, validation and utilization of objective tools to assess the technical skills of trainees remains elusive. The objectives of this project are to develop models to identify predictive factors for fellow performance, validate the Global Operative Assessment of Laparoscopic Skills (GOALS) as an assessment tool for laparoscopic skills, and to define the learning curve for complex laparoscopic gastrointestinal surgery. METHODS: Using previously recorded data from a centralized database of the Fellowship Council, we analyzed the voluntarily submitted performance scores of surgical fellows for three complex laparoscopic gastrointestinal operations: Roux-en-Y gastric bypass, LapBand placement, and Nissen fundoplication. We analyzed previous experience with complex cases, previous experience with the same type of case, case difficulty, and time of year in the fellowship as potential predictors of performance. Performance scores throughout the fellowship year were graphed to create learning curves for overall performance and each of five domains of performance. RESULTS: Ninety-eight performance assessments were submitted for 31 unique fellows. Overall performance (p < 0.01), bimanual dexterity (p < 0.01), efficiency (p < 0.01), and autonomy (p < 0.01) all improved significantly throughout the course of the fellowship year. Performance in the domains of depth perception and tissue handling improved, but the improvement did not reach statistical significance. Three predictor variables were significantly related to performance scores. CONCLUSIONS: This study documents that GOALS is able to differentiate novice fellows from graduating fellows and established construct validity. Models developed and tested confirmed that previous experience, case difficulty, and length of time as a fellow impacted performance.
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Competencia Clínica , Procedimientos Quirúrgicos del Sistema Digestivo/educación , Educación Médica Continua/métodos , Internado y Residencia , Laparoscopía/educación , Curva de Aprendizaje , Humanos , Estudios RetrospectivosRESUMEN
Most firearm-related injuries are nonfatal and require hospitalization. Using data on 3,257,720 hospitalizations from the National Hospital Discharge Survey (2000-2010), we determined overall and cause-, gender-, and race-specific trends in firearm-related hospitalization (FRH) and determinants of in-hospital firearm mortality. Types of FRH evaluated, according to International Classification of Diseases, Ninth Revision, Clinical Modification, E-diagnostic codes, were accident (codes E922.0-E922.3, E922.8, and E922.9), assault (codes E965.0-E965.4), attempted suicide (codes E955.0-E955.4), legal intervention (code E970), undetermined intent (codes E985.0-E985.3), and war (code E991). A moderate reduction in FRH rates was observed from 2000 to 2011: from 62 FRHs per 100,000 hospitalizations to 57 per 100,000 (P-trend = 0.0016). The majority of FRHs were due to assault (P-trend = 0.19) or accident (P-trend = 0.32) and showed no significant reduction in rates over time, whereas rates for 14% of all FRHs-those due to attempted suicide (P-trend = 0.002) and undetermined intent (P-trend = 0.0029)-declined moderately. Moderate declines were observed among both blacks (from 213.1 FRHs per 100,000 hospitalizations to 164.4 per 100,000; P-trend = 0.049) and whites (from 38.4 FRHs per 100,000 hospitalizations to 32.2 per 100,000; P-trend = 0.031). The decline was significant only among men (effect size = 0.9, P-trend = 0.004). In conclusion, the reduction in FRH was driven by a reduction in self-inflicted and undetermined injuries. FRH rates were 6-fold greater among blacks than among whites and 14-fold greater in men than in women throughout the period.
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Mortalidad Hospitalaria/tendencias , Hospitalización/tendencias , Heridas por Arma de Fuego/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/etiología , Heridas por Arma de Fuego/mortalidad , Heridas por Arma de Fuego/terapia , Adulto JovenRESUMEN
Single port access surgery (SPAS) presents surgeons with added challenges that require new surgical tools and surgical assistance systems with unique capabilities. To address these challenges, we designed and constructed a new insertable robotic end-effectors platform (IREP) for SPAS. The IREP can be inserted through a Ø15 mm trocar into the abdomen and it uses 21 actuated joints for controlling two dexterous arms and a stereo-vision module. Each dexterous arm has a hybrid mechanical architecture comprised of a two-segment continuum robot, a parallelogram mechanism for improved dual-arm triangulation, and a distal wrist for improved dexterity during suturing. The IREP is unique because of the combination of continuum arms with active and passive segments with rigid parallel kinematics mechanisms. This paper presents the clinical motivation, design considerations, kinematics, statics, and mechanical design of the IREP. The kinematics of coordination between the parallelogram mechanisms and the continuum arms is presented using the pseudo-rigid-body model of the beam representing the passive segment of each snake arm. Kinematic and static simulations and preliminary experiment results are presented in support of our design choices.
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BACKGROUND: The objective of this project is to document the history of the Fellowship Council (FC) and report its current impact on surgical training. The need for advanced training in laparoscopic surgery resulted in the rapid development of fellowships for which there was no oversight. Fellowship program directors began meeting in the 1990s and formally created the FC in 2004 to provide that oversight. METHODS: To obtain information with which to create a narrative of the history of the FC, the authors performed a detailed review of all available minutes from the meetings of the various iterations of the council and its committees between 2001 and 2012. Information about fellowships and meetings of the directors of fellowships prior to 2001 are based on information included in minutes of meetings after 2001. RESULTS: Minimally invasive surgery fellowship program directors in collaboration with surgical societies created the FC to bring order to the application process for residents and program directors. It has evolved into an organization with mature, reliable processes for application, matching, curriculum development, accreditation, and reporting. It now receives applications from more than 30 % of graduating chief residents in general surgery. It has 223 accredited fellowship positions in the following disciplines: Minimally invasive surgery, bariatric/metabolic surgery, Flexible endoscopy, hepato-pancreato-biliary Surgery, colorectal surgery, and Thoracic surgery. CONCLUSIONS: The FC provides a reliable, fair process for matching residents with fellowship programs and has successfully expanded its oversight of such programs with mature processes for accreditation, curriculum development, and reporting.
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Educación de Postgrado en Medicina/organización & administración , Becas/organización & administración , Cirugía General/educación , Procedimientos Quirúrgicos Operativos/educación , Acreditación/normas , Cirugía Bariátrica/educación , Competencia Clínica , Miembro de Comité , Curriculum , Educación de Postgrado en Medicina/historia , Endoscopía/educación , Becas/economía , Becas/historia , Organización de la Financiación , Cirugía General/métodos , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Laparoscopía/educación , Procedimientos Quirúrgicos Mínimamente Invasivos/educación , Sociedades MédicasRESUMEN
INTRODUCTION: Virtual reality simulators contribute to basic laparoscopic skill acquisition. These trainers have not yet been shown to contribute to the acquisition of more advanced laparoscopic skills as measured by the Fundamentals of Laparoscopic Surgery (FLS). We have customized novel basic and advanced curricula for the LapSim trainer (Surgical Science, Göteborg, Sweden). Successful completion of these programs is required of our residents. We hypothesize that the successful completion of our advanced curriculum will result in the significant improvement of our residents' advanced laparoscopic skills as measured by the FLS skills scores. METHODS: In all, 23 surgical residents (PGY 1-4), who had already passed our basic skills curriculum, completed our advanced LapSim curriculum. All individuals underwent FLS skills testing before and after completing the training. Laparoscopic case experience during the training period was documented for all trainees. FLS scores were analyzed by t test and controlled for case experience. RESULTS: Posttraining FLS scores demonstrate a significant increase for all residents from a mean of 57-66 (p < 0.02), especially for seniors (PGY 3-4): 56-68 (p < 0.01). The operative laparoscopic case volume ranged from 1-90 (mean, 30) for juniors (PGY 1-2) and 12-76 (mean 50) for seniors during the training period. Junior resident FLS improvement was dependent on case volume during the period of training; residents with less than 30 cases had a mean improvement of 0, whereas those with at least 30 cases had a 15 point improvement (p < 0.01). Senior resident FLS score improvement was independent of case numbers during the training period. CONCLUSIONS: Completion of our advanced LapSim curriculum results in improved advanced laparoscopic skills in senior residents as measured by FLS scores. This skill improvement is independent of laparoscopic case experience. Continuing to mandate the use of this skills curriculum should improve our residents' performance in advanced laparoscopic surgical procedures.
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Competencia Clínica , Educación de Postgrado en Medicina/métodos , Laparoscopía/educación , Mejoramiento de la Calidad , Interfaz Usuario-Computador , Centros Médicos Académicos , Adulto , Simulación por Computador , Connecticut , Curriculum , Educación Médica Continua/métodos , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Cervical esophagogastric anastomotic disruption following transhiatal esophagectomy (THE) is a significant problem. Gastric tip ischemia is a primary cause of anastomotic failure. We examined gastric tip blood flow when laparoscopic "ischemic preconditioning" was attempted by selectively ligating the short gastric (SG) vessels or both the left and short gastric (LG/SG) vessels prior to THE. METHODS: Seventeen (25 kg) mongrel dogs underwent laparoscopy followed 3 weeks later by THE. Three groups were studied: control group = laparoscopy only, no preconditioning (n = 6); SG group = laparoscopic ligation of SG vessels only (n = 5); and LG/SG group = laparoscopic ligation of LG and SG vessels (n = 6). Tissue blood flow was assessed using the fluorescent microsphere method. The initial microsphere injections occurred prior to pneumoperitoneum and upon completion of the laparoscopy. At the second operation, transhiatal esophagectomy was performed and microsphere blood flow assessment occurred after induction of anesthesia, after mobilization of the stomach, and after completion of the cervical esophagogastric anastomosis. The animals were euthanized and regional gastric tissue was analyzed for microsphere estimates of blood flow. Differences in blood flow were evaluated using Student's t test. RESULTS: The mean baseline gastric blood flow was 0.58 ml/min/g. After THE, the proximal gastric blood flow fell to 16% of baseline in control and 22% in SG, but was reduced to only 60% of baseline in LG/SG. This relative preservation of blood flow among the LG/SG group approached significance compared with the laparoscopy-only (control) group (P = 0.07). Ligation of SG vessels alone provided no preservation of proximal gastric blood flow following THE. CONCLUSION: Preoperative "ischemic preconditioning" through ligation of both the short and left gastric vessels may achieve preservation of blood flow to the gastric tip. Preconditioning during laparoscopic staging of esophageal carcinoma may be considered to reduce anastomotic complications following esophagectomy.
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Esofagectomía/métodos , Precondicionamiento Isquémico/métodos , Laparoscopía , Estómago/irrigación sanguínea , Fuga Anastomótica/prevención & control , Animales , Perros , MasculinoRESUMEN
BACKGROUND: The challenges of teaching and learning technical skills for laparoscopic surgery have limited the use of laparoscopy for complex abdominal surgery. In an attempt to facilitate learning these skills, surgical educators are using simulators, but there is little conclusive evidence that simulators can predict improved performance by surgical trainees receiving training on them (predictive validity). METHODS: In the present study the results of three attempts to establish predictive validity for a virtual laparoscopic simulator were reviewed. In each study, the performance of surgery residents before and after training on the simulator was documented by means of a validated assessment tool, and then the results were compared. RESULTS: Some task performance was improved by training on the simulator, but predictive validity could not be established for the simulator in any of the three attempts to do so. CONCLUSIONS: Although predictive validity for the virtual simulator was not conclusively established, reasons for this failure are discussed. Based on the evidence that training on simulators results in some task performance improvement, future studies are justified to better define more effective use of the simulator.
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Competencia Clínica , Educación de Postgrado en Medicina/métodos , Endoscopía/educación , Laparoscopía , Interfaz Usuario-Computador , Evaluación Educacional , Humanos , Internado y Residencia , Estudios Prospectivos , Análisis y Desempeño de TareasRESUMEN
BACKGROUND: Although video-laparoscopy has enabled successful minimal access surgery, the nature of the technology causes many troublesome limitations: (1) the fulcrum effect of the insertion site through the abdominal wall limits the angle of view, (2) the camera operator must use counterintuitive movements, (3) the laparoscope occupies an incision which otherwise could be used for an instrument, and (4) the laparoscope provides a two-dimensional image. METHODS: A stereoscopic, insertable, remotely controlled camera was developed to overcome the limitations imposed by traditional video-laparoscopy. Additional functionality included digital zoom, picture-in-picture (PIP), and tracking capability for autonomous function of the camera. Four surgical tasks were performed twice in a porcine model, once using the insertable camera and once using a standard video-laparoscope setup for visualization. Running the bowel, simulated laparoscopic appendectomy, laparoscopic nephrectomy, and laparoscopic suturing and tying were measured for time, blood loss, and complications. Digital zoom, PIP, and the ability of the computer to move the camera to track a marked instrument were subjectively evaluated. RESULTS: The tasks were aborted in one animal because a new three-dimensional (3D) display could not be synchronized with the camera and in another animal because a motor in the camera failed. The tasks were all completed twice in two animals. The mean time was less for all procedures using the insertable camera. There was no significant blood loss and there were no complications. Digital zoom and PIP displaying both a close-up and a panoramic view were subjectively felt to improve visualization by all observers. The computer could reliably move the camera to track a marked instrument to keep it in the center of the field of view. CONCLUSIONS: This preliminary proof-of-concept study suggests that a stereoscopic, insertable, remotely controlled camera may provide better visualization during minimal access surgery by overcoming many of the limitations of video-laparoscopy.
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Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Fotograbar/instrumentación , Animales , Femenino , Laparoscopía , Modelos Animales , PorcinosRESUMEN
PURPOSE: To determine whether LapSim training (version 3.0; Surgical Science Ltd, Göteborg, Sweden) to criteria for novice PGY1 surgical residents had predictive validity for improvement in the performance of laparoscopic cholecystectomy. METHODS: In all, 21 PGY1 residents performed laparoscopic cholecystectomies in pigs after minimal training; their performance was evaluated by skilled laparoscopic surgeons using the validated tool GOALS (global operative assessment of laparoscopic operative skills: depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). From the group, 10 residents trained to competency on the LapSim Basic Skills Programs (camera navigation, instrument navigation, coordination, grasping, lifting and grasping, cutting, and clip applying). All 21 PGY1 residents again performed laparoscopic cholecystectomies on pigs; their performance was again evaluated by skilled laparoscopic surgeons using GOALS. Additionally, we studied the rate of learning to determine whether the slow or fast learners on the LapSim performed equivalently when performing actual cholecystectomies in pigs. Finally, 6 categorical residents were tracked, and their clinical performance on all of the laparoscopic cholecystectomies in which they were "surgeon, junior" was prospectively evaluated using the GOALS criteria. RESULTS: We found a statistical improvement of depth perception in the operative performance of cholecystectomies in pigs in the group trained on the LapSim. In the other 4 domains, a trend toward improvement was observed. No correlation between being a fast learner and the ultimate skill was demonstrated in the clinical performance of laparoscopic cholecystectomies. We did find that the fast learners on LapSim all were past or current video game players ("gamers"); however, that background did not translate into better clinical performance. CONCLUSIONS: Using current criteria, we doubt that the time and effort spent training novice PGY1 Surgical Residents on the basic LapSim training programs is justified, as such training to competence lacks predictive validity in most domains of the GOALS program. We are investigating 2 other approaches: more difficult training exercises using the LapSim system and an entirely different approach using haptic technology (ProMis; Haptica Ltd., Ireland), which uses real instruments, with training on realistic 3-dimensional models with real rather than simulated cutting, sewing, and dissection. Although experienced video gamers achieve competency faster than nongamers on LapSim programs, that skill set does not translate into improved clinical performance.
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Colecistectomía Laparoscópica/educación , Educación de Postgrado en Medicina/métodos , Internado y Residencia , Interfaz Usuario-Computador , Adulto , Animales , Competencia Clínica , Simulación por Computador , Curriculum , Percepción de Profundidad , Evaluación Educacional , Femenino , Humanos , Masculino , Estudios Prospectivos , Porcinos , Juegos de VideoRESUMEN
Laparoscopic imaging has remained relatively unchanged since the introduction of the rod-lens system. The intent here is to improve imaging by designing and building sensors and effectors placed directly into the body and controlled remotely. An 11-mm monoscopic insertable pan/tilt endoscopic imaging device with an integrated light source was studied. In vivo testing included simulated appendectomy, nephrectomy, suturing, and running the bowel in a porcine model (n = 6). Subjective impression and time for each procedure were compared using each imaging modality. The insertable imaging device seemed easier and more intuitive to use than a standard laparoscope. Time to perform procedures was better than or equivalent to a standard laparoscope. The insertable camera was subjectively preferred, and times for completion of complex tasks were shorter using the insertable camera. The insertable imaging device has the potential to be an integral part of surgical system platforms.
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Apendicectomía/instrumentación , Laparoscopios , Laparoscopía , Nefrectomía/instrumentación , Robótica/instrumentación , Cirugía Asistida por Video/instrumentación , Animales , Diseño de Equipo , Femenino , Modelos Animales , Técnicas de Sutura , PorcinosRESUMEN
The use of high-definition cameras and monitors during minimally invasive procedures can provide the surgeon and operating team with more than twice the resolution of standard definition systems. Although this dramatic improvement in visualization offers numerous advantages, the adoption of high definition cameras in the operating room can be challenging because new recording equipment must be purchased, and several new technologies are required to edit and distribute video. The purpose of this review article is to provide an overview of the popular methods for recording, editing, and distributing high-definition video. This article discusses the essential technical concepts of high-definition video, reviews the different kinds of equipment and methods most often used for recording, and describes several options for video distribution.
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Procedimientos Quirúrgicos Mínimamente Invasivos , Grabación en Video/métodos , Presentación de Datos , Diseño de Equipo , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Grabación en Video/instrumentación , Grabación de Videodisco , Grabación de Cinta de VideoRESUMEN
We describe a surgical imaging device with pan, tilt, zoom and integrated LED light source. It can be fully inserted into the abdomen, leaving the insertion port free for tooling. Using a porcine model we have tested the device and performed surgical procedures including cholecystectomy, appendectomy, running (measuring) the bowel, suturing, and nephrectomy. The tests show that the new device is: * Easier and more intuitive to use than a standard laparoscope. * Joystick operation requires no specialized operator training. * Field of view and access to relevant regions of the body were superior to a standard laparoscope using a single port. * Time to perform procedures was better or equivalent to a standard laparoscope. We believe these insertable platforms will be an integral part of future surgical systems.
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Endoscopios , Luz , Cirugía Asistida por Video/instrumentación , Animales , Diseño de Equipo , Ciudad de Nueva York , PorcinosRESUMEN
INTRODUCTION: Without ongoing practice, acquired motor skills may deteriorate over time. The purpose of this study is to document the level of retention of laparoscopic skills over time. METHODS: Thirty-three general-surgery PGY 1, 2, and 3 residents trained to established criteria and passed an exam for each of seven technical skills (camera navigation, instrument navigation, camera/instrument coordination, grasping, lifting and grasping, cutting, and clip applying) on a virtual simulator (LapSim Surgical Science Ltd., Göteborg, Sweden). Six months later, the residents again completed the exam for each of the seven skills. During the 6 months, the simulators were available, but additional practice was not required. The retesting process consisted of three attempts, the first of which was acclimatization. The results of the subsequent two exams were compared with baseline data. RESULTS: At retest, the number of residents who passed clip applying (7, 21%) and cutting tasks (18, 55%) was significantly lower than for the other five tasks (p < 0.05). In failed tests, instrument wandering and tissue damage were more common than increases in task time. Upper-level residents were significantly more likely to pass than first-year residents were (p < 0.01). Time of day did not influence passing rates. CONCLUSION: Six months after training to criteria, instrument and tissue-handling skills deteriorated more than the speed with which a task is completed. Evidence of skill retention was present for some but not all tasks. Fine motor skills, required to perform more difficult tasks, deteriorated more than skills needed for easier tasks.
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Competencia Clínica , Cirugía General/educación , Internado y Residencia , Laparoscopía , Destreza Motora , Práctica Psicológica , Factores de Tiempo , Adulto , Evaluación Educacional , Humanos , Laparoscopía/métodos , Desempeño PsicomotorRESUMEN
BACKGROUND: Virtual reality simulators are a component of the armamentarium for training surgical residents. No one knows exactly how to incorporate virtual reality simulators into a curriculum. The purpose of this study was to document and show the learning curve and test-retest reliability of 2 tasks on a virtual reality-training simulator (LapSim; Surgical Science, Göteborg, Sweden) in laparoscopic surgery. METHODS: Twenty-nine medical students participated in 8 iterations of 7 virtual reality tasks ("camera navigation" (CN), "instrument navigation," "coordination," "grasping," "lifting and grasping" (LG), "cutting," and "clip applying") Learning curves for each outcome variable of the CN and LG tasks were generated. Using ANOVA, we evaluated the differences between each score from attempt number 7 to attempt number 8 to document test-retest reliability. RESULTS: A plateau in the learning curve occurred within 8 sessions for CN misses, CN tissue damage, CN maximum damage, and LG maximum damage. Over the course of 8 sessions, a plateau in the learning curve was nearly reached for CN time, CN drift, CN path, CN angular path, and LG left and right path. The following variables had a downward trend to the mean learning curve over 8 sessions, but they did not reach a plateau: LG time, LG left and right miss, LG left and right angular path, and LG tissue damage. CONCLUSION: Using the LapSim virtual reality simulator, we documented a learning curve and test-retest reliability for each outcome variable for CN and LG for rank novices. The modeling of the general learning curve is useful in designing training program. These results may be important in developing standards for technical evaluation in a surgical training curriculum.
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Competencia Clínica , Cirugía General/educación , Laparoscopía , Análisis y Desempeño de Tareas , Adulto , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Enseñanza/métodos , Interfaz Usuario-ComputadorRESUMEN
The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid assessment tool for objectively evaluating the technical performance of laparoscopic skills in surgery residents. We hypothesized that GOALS would reliably differentiate between an experienced (expert) and an inexperienced (novice) laparoscopic surgeon (construct validity) based on a blinded videotape review of a laparoscopic cholecystectomy procedure. Ten board-certified surgeons actively engaged in the practice and teaching of laparoscopy reviewed and evaluated the videotaped operative performance of one novice and one expert laparoscopic surgeon using GOALS. Each reviewer recorded a score for both the expert and the novice videotape reviews in each of the 5 domains in GOALS (depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). The scores for the expert and the novice were compared and statistically analyzed using single-factor analysis of variance (ANOVA). The expert scored significantly higher than the novice did in the domains of depth perception (p = .005), bimanual dexterity (p = .001), efficiency (p = .001), and overall competence ( p = .001). Interrater reliability for the reviewers of the novice tape was Cronbach alpha = .93 and the expert tape was Cronbach alpha = .87. There was no difference between the two for tissue handling. The Global Operative Assessment of Laparoscopic Skills is a valid, objective assessment tool for evaluating technical surgical performance when used to blindly evaluate an intraoperative videotape recording of a laparoscopic procedure.
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Colecistectomía Laparoscópica , Competencia Clínica , Grabación de Cinta de Video , Colecistectomía Laparoscópica/educación , Cirugía General/educación , Humanos , Periodo Intraoperatorio , Análisis y Desempeño de TareasRESUMEN
BACKGROUND: The Global Operative Assessment of Laparoscopic Skills (GOALS), developed by Vassiliou and colleagues, has construct validity in the assessment of surgical residents' laparoscopic skills in dissection of the gallbladder from the liver bed. We hypothesized that GOALS would have construct validity for the entire laparoscopic cholecystectomy procedure and also for laparoscopic appendectomy. METHODS: Using GOALS, attending surgeons evaluated PGY1 through PGY5 surgical resident performance during laparoscopic cholecystectomy (LC, n = 51) and laparoscopic appendectomy (LA, n = 43). Scores for five domains (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) were recorded on a Web-based operative report generator at the conclusion of all cases. Domain scores were recorded using a 5-point Likert scale. Difficulty of the case was similarly rated on a 5-point scale. For analysis, residents were divided into two groups: novice (PGY1 to 3) and experienced (PGY4 to 5). Biostatistical analysis was performed using a two-sample t-test. Paired t-test was used to compare mean scores of residents who performed both LA and LC. RESULTS: For both LC and LA, the experienced group scored higher than novices did in all five domains. The differences were significant in all domains. Using the mean of the scores from all 5 domains for both LC and LA, the experienced residents scored significantly better than novices did (LC 3.93 versus 2.76, p < 0.001) (LA 4.22 versus 2.75, p < 0.001). No significant differences were noted in difficulty of the cases (p = 0.060 for LC and p = 0.19 for LA). CONCLUSIONS: This study provides additional evidence in support of GOALS as an assessment tool for objectively measuring technical skills in laparoscopic surgery.