Quantification of Surgical Workflow during Robotic Proctectomy.

Aim: Assessments of surgical workflow offer insight regarding procedure variability, case complexity and surgeon proficiency. We utilize an objective method to evaluate step-by-step workflow and step transitions during robotic proctectomy (RP). Methods: We annotated 31 RPs using a procedure-specific annotation card. Using Spearman's correlation, we measured strength of association of step time and step visit frequency with console time (CT) and total operative time (TOT). Results: Across 31 RPs, a mean (± standard deviation) of 49.0 (± 20.3) steps occurred per procedure. Mean CT and TOT were 213 (± 90) and 283 (± 108) minutes. Posterior mesorectal dissection required most visits (8.7 ± 5.0), while anastomosis required most time (18.0 [± 8.5] minutes). Inferior mesenteric vein (IMV) ligation required least visits (1.0 ± 0.0) and lowest duration (0.9 [± 0.5] minutes). Strong correlations were seen with CT and step times for IMV dissection and ligation (ρ = 0.60 for both), lateral-to-medial splenic flexure mobilization (SFM) (ρ = 0.63), left rectal dissection (ρ = 0.64) and mesorectal division (ρ = 0.71). CT correlated strongly with medial-to-lateral and supracolic SFM visit frequency (ρ = 0.75 and ρ = 0.65). There were strong correlations with TOT and initial exposure time (ρ = 0.60), as well as visit frequency for medial-to-lateral (ρ = 0.67) and supracolic SFM (ρ = 0.65). Descending colon mobilization was nodal, rectal mobilization convergent and rectal transection divergent. Conclusion: This study correlates individual surgical steps with CT and TOT through standardized annotation. It provides an objective approach to quantify workflow.

A simulation-based curriculum can be used to teach open intestinal anastomosis.

BACKGROUND: Simulation is a technique commonly used to teach technical skills such as those necessary in laparoscopic surgery. Curricula with objective, validated metrics rating performance are widely used. Simulations to develop and assess skills necessary for open surgical procedures are less common. We hypothesized that a curriculum designed to teach the skills necessary to perform open laparotomy and bowel anastomosis would result in improved knowledge of the procedure steps, increased technical skills, and improved confidence in novice surgeons. METHODS: A simulation-based curriculum designed to teach open laparotomy and bowel anastomosis was developed. Eleven surgical interns participated in the 6-wk curriculum. Written surveys regarding confidence in the knowledge and ability to perform these procedures were administered before and after the curriculum. Videos of the first six subjects were created on the first and final repetition of the simulation. An Objective Assessment of Technical Skills (OSATS) instrument was used to evaluate each video by two independent, blinded reviewers. RESULTS: Subjects demonstrated significantly improved OSATS scores for skills and knowledge in seven of nine domains assessed upon completion of the curriculum. Subject confidence in laparotomy and bowel anastomosis skills improved significantly. CONCLUSION: A structured, simulation-based curriculum designed to teach laparotomy and hand-sewn bowel anastomosis skills is effective and increases participant confidence. Further study is required to determine whether simulation results in improved performance in the operating room.

Endoscopic changes in the upper airway after mandibular distraction osteogenesis.

INTRODUCTION: Children with micrognathia secondary to craniofacial disorders can experience significant airway and feeding difficulties. Mandibular distraction osteogenesis (MDO) is one treatment of severe micrognathia. We examined endoscopic images for upper airway (UA) soft tissue changes after MDO. We hypothesized that MDO produces consistent changes in UA soft tissue, which correlate with symptom resolution. MATERIALS AND METHODS: This retrospective chart review included 16 patients undergoing MDO from 2002 to 2007. Demographic data, symptom information, and preoperative and early and late postoperative endoscopic images were collected. Blinded randomized images of UA soft tissues were quantitatively analyzed using ImageJ. To compare nonstandardized images, ratios of UA dimensions were made. Preoperative and early and late postoperative ratios were statistically analyzed with Student's t-test. RESULTS: Sixteen patients with a mean age of 237 days were included. Mean distance distracted was 12 mm. There were significant changes in relative dimensions of the supraglottic space in the early postoperative period, which were not maintained in the late postoperative period. Nevertheless, all experienced complete relief of airway obstruction. DISCUSSION: Our study showed a significant increase in supraglottic space dimensions after MDO that was not maintained over time. This is likely because of the limitation of images and measurement methods. Despite this, significant clinical improvement was seen in all patients, with resolution of airway obstruction. This suggests supraglottic changes as well as tongue base alterations are related to clinical improvement. Further investigation of alterations in UA after MDO is needed to continue characterizing these changes.