Evaluation of operating room inefficiencies and their impact on operating room duration using a surgical app.

BACKGROUND: Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures. MATERIALS: Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis. RESULTS: 151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 â€‹min delay (p â€‹< â€‹0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined. CONCLUSION: The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time.

SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS: A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS: The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION: Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM).

BACKGROUND: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. METHODS: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. RESULTS: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. CONCLUSIONS: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5 cm: a systematic review and meta-analysis.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm. METHODS: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data. RESULTS: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm. CONCLUSION: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis.

BACKGROUND: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor. METHODS: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD). RESULTS: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17). CONCLUSIONS: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

Guidelines for the performance of minimally invasive splenectomy.

BACKGROUND: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. OBJECTIVE: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. RESULTS: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. CONCLUSIONS: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis.

BACKGROUND: Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia. METHODS: We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively. RESULTS: From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. CONCLUSIONS: POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.

Characterizing robotic surgical expertise: An exploratory study of neural activation during mental imagery of robotic suturing.

BACKGROUND: Mental imagery (MI) aids skill acquisition, however, it is unclear to what extend MI is used by experienced surgeons. The purpose of this study was to assess differences in MI of participants with varying surgical expertise in robotic surgery. METHODS: Students, residents, and surgeons completed the Mental Imagery Questionnaire to assess MI for robotic suturing. Participants then completed robotic simulator tasks, and imagined performing robotic suturing while being assessed with electroencephalogram (EEG). RESULTS: Attending surgeons reported higher MI for robotic suturing, and EEG revealed higher neural activation during imagery of robotic suturing than other groups. CONCLUSIONS: Experienced surgeons displayed higher MI ability for robotic suturing, and displayed higher cortical activity in the frontal and parietal areas of the brain, which is associated with more advanced motor imagery. MI appears to be a component of robotic surgery expertise.

What delays your case start? Exploring operating room inefficiencies.

INTRODUCTION: Improving operating room (OR) inefficiencies benefits the OR team, hospital, and patients alike but the available literature is limited. Our goal was, using a novel surgical application, to identify any OR incidents that cause delays from the time the patient enters the OR till procedure start (preparatory phase). MATERIALS AND METHODS: We conducted an IRB approved, prospective, observational study between July 2018 and January 2019. Using a novel surgical application (ExplORer Surgical) three observers recorded disrupting incidents and their duration during the preparatory phase of a variety of general surgery cases. Specifically, the number and duration of anesthesia delays, unnecessary/distracting conversations, missing items, and other delays were recorded from the moment they started until they stopped affecting the normal workflow. RESULTS: Ninety-six OR cases were assessed. 20 incidents occurred in 18 (19%) of those cases. The average preparatory duration for all the cases was 20.7 ± 8.6 min. Cases without incidents lasted 19.5 ± 7.4 min while cases with incidents lasted 25.9 ± 11.2 min, p = 0.03. The average incident lasted 3.7 min, approximately 18% of the preparatory phase duration. CONCLUSION: The use of the ExplORer Surgical app allowed us to accurately record the incidents happening during the preparatory phase of various general surgery operations. Such incidents significantly prolonged the preparatory duration. The identification of those inefficiencies is the first step to targeted interventions that may eventually optimize the efficiency of preoperative preparation.

Comparison of operating room inefficiencies and time variability in laparoscopic gastric bypass.

BACKGROUND: Improving operating room (OR) inefficiencies has financial and operational ramifications. However, their incidence has not been systematically studied, especially in bariatric surgery. OBJECTIVES: The study aimed to identify the operational inefficiencies of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure, specify the steps of the procedure, and investigate whether the inefficiencies are related to case-by-case variability, using a surgical application. SETTING: University Hospital, United States METHODS: From July 2018 to January 2019, we observed consecutive nonrevisional LRYGB cases. We used a surgical application to capture in real-time all the inefficiencies/incidents that occurred inside the operating room. The duration and time variability, along with the number of incidents of each step, were recorded. Additionally, a multivariable analysis was conducted to investigate whether patient factors (age, race, body mass index, and American Society of Anesthesiologists physical status classification), surgeon and surgical-technician experience, resident-assist, and case difficulty affect the number of incidents. RESULTS: Forty LRYGB procedures were observed. The duration of the procedural steps was linearly correlated with the number of incidents but case-to-case step duration variability was not. The steps that were linked with more inefficiencies included jejunojejunostomy creation that included more unrelated to the case conversations, and gastric pouch creation that had more anesthesia-related delays. Inefficiencies such as equipment malfunctions and missing supplies were equally distributed among all the steps. Multivariable analysis did not indicate that any of the tested factors were associated with the number of incidents. CONCLUSION: The use of the surgical app allowed us to accurately record the duration, variability, and the undesired incidents of each LRYGB procedural step. Future studies should target interventions to minimize the inefficient procedural steps we have identified to optimize operating room efficiency.

Mental skills training limits the decay in operative technical skill under stressful conditions: Results of a multisite, randomized controlled study.

BACKGROUND: Overwhelming stress in the operating room can lead to decay in operative performance, particularly for residents who lack experience. Mental skills training can minimize deterioration in performance during challenging situations. We hypothesized that residents trained on mental skills would outperform controls under increased stress conditions in the simulated operating room. METHODS: Residents from Indiana University enrolled voluntarily in this institutional review board-approved study. Residents were stratified according to baseline characteristics and randomized into a mental skills and control group. Both groups trained to proficiency in laparoscopic suturing, but only the mental skills group received mental skills training. After training, technical skill transfer was assessed under regular and stressful conditions on a porcine model. Performance was assessed using an objective suturing score. The Test of Performance Strategies was used to assess the use of mental skills. Data were combined and compared with data that had been collected at Carolinas Healthcare System because residents underwent the same protocol. RESULTS: A total of 38 residents completed all study elements. There were no differences in the effects observed between sites. We observed no group differences at baseline. The groups achieved similar technical performance at baseline, posttest, and transfer test under low-stress conditions, but the mental skills group outperformed the control group during the transfer test under high-stress conditions. CONCLUSION: Our comprehensive mental skills curriculum implemented with surgery residents at two institutions was effective at minimizing the deterioration of resident technical performance under stressful conditions compared with controls. These results provide further evidence for the effectiveness of mental skills training to optimize surgery trainees' technical performance during challenging clinical situations.

Performance variability during training on simulators is associated with skill transfer.

BACKGROUND: Expert performance is characterized by consistency. The degree of variability of performance from repetition to repetition during proficiency-based simulator training could potentially indicate acquisition of expertise. We hypothesized that learners with less variability in performance during simulator training would achieve greater performance at the end of training and improved transfer of skills to a live, anesthetized, porcine model. METHODS: The performance of 93 subjects (surgery residents and medical students) who had participated in 3 randomized controlled trials was analyzed for variability. All participants had trained in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery (FLS) simulator. Their performance had been assessed on the simulator before (baseline) and after training (posttest) and on a live, anesthetized, porcine model (transfer test). We computed the coefficient of variations of suturing scores during training for each participant. Linear regression was used to assess whether variability in performance during training predicted posttest and transfer-test scores. RESULTS: Decreased practice variability in performance was associated with greater scores in posttests and transfer tests. For each percent decrease in variability performance, posttest scores increased by 3.8 points (P < .001) and transfer-test scores increased by 3.0 points (P < .001). Greater mean scores during practice were associated with greater scores on the transfer test (P < .001). CONCLUSION: Decreased variability in performance during practice on simulators is associated with improved performance at the end of training and during transfer to a live, anesthetized, porcine model. These findings suggest that variability in performance during simulator training may be used to track the progress and readiness of a trainee for the clinical environment. Further studies are needed to verify the robustness of this potentially new metric of performance.

Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.

INTRODUCTION: Several studies demonstrated that simulator-acquired skill transfer to the operating room is incomplete. Our objective was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. METHODS: Trainees completed baseline assessments including intracorporeal suturing (IS) performance, attentional selectivity, self-reported use of mental skills, and self-reported prior clinical and simulated laparoscopic experience and confidence. Residents then followed proficiency-based laparoscopic skills training, and their skill transfer was assessed on a live-anesthetized porcine model. Predictive characteristics for transfer test performance were assessed using multiple linear regression. RESULTS: Thirty-eight residents completed the study. Automaticity, attentional selectivity, resident perceived ability with laparoscopy and simulators, and post-training IS performance were predictive of IS performance during the transfer test. CONCLUSIONS: Promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. Mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal.