Does speed equal quality? Time pressure impairs minimally invasive surgical skills in a prospective crossover trial.

BACKGROUND: Time pressure can cause stress, subsequently influencing surgeons during minimally invasive procedures. This trial aimed to investigate the effect of time pressure on surgical quality, as assessed by force application and errors during minimally invasive surgical tasks. METHODS: Sixty-three participants (43 surgical novices trained to proficiency and 20 surgeons) performed four laparoscopic tasks (PEG transfer, precise Cutting, balloon resection, surgical knot) both with and without time pressure. The primary endpoint was the mean and maximal force exertion during each task. Secondary endpoints were the occurrence of predefined errors and the self-assessed stress level. RESULTS: Time pressure led to a significant shortening of the task time in all four tasks. However, significantly more errors were noticed under time pressure in one task (suture precision P < 0.001). Moreover, time pressure led to a significant increase in mean force in all tasks (PEG: P < 0.001; precision cutting: P = 0.001; surgical knot: P < 0.001; balloon: P = 0.004). In three tasks the maximal force application (PEG: P < 0.001; precision cutting: P < 0.001; surgical knot: P = 0.006) increased significantly. Performing the tasks under time pressure significantly increased the stress level. Cohort analysis revealed that time pressure impaired the performance of both, surgical novices and surgeons but novices were more strongly affected compared to surgeons. CONCLUSION: Time pressure during minimally invasive surgery may improve procedural time but impair the quality of surgical performance in terms of the incidence of errors and force exertion. Experience may only partially compensate for the negative influence of time pressure.

Short-term preoperative drainage is associated with improved postoperative outcomes compared to that of long-term biliary drainage in pancreatic surgery.

PURPOSE: The treatment of choice for patients presenting with obstructive cholestasis due to periampullary carcinoma is oncologic resection without preoperative biliary drainage (PBD). However, resection without PBD becomes virtually impossible in patients with obstructive cholangitis or severely impaired liver cell function. The appropriate duration of drainage by PBD has not yet been defined for these patients. METHODS: A retrospective analysis was conducted on 170 patients scheduled for pancreatic resection following biliary drainage between January 2012 and June 2018 at the University Hospital Dresden in Germany. All patients were deemed eligible for inclusion, regardless of the underlying disease entity. The primary endpoint analysis was defined as the overall morbidity (according to the Clavien-Dindo classification). Secondary endpoints were the in-hospital mortality and malignancy adjusted overall and recurrence-free survival rates. RESULTS: A total of 170 patients were included, of which 45 (26.5%) and 125 (73.5%) were assigned to the short-term (< 4 weeks) and long-term (≥ 4 weeks) preoperative drainage groups, respectively. Surgical complications (Clavien-Dindo classification > 2) occurred in 80 (47.1%) patients, with significantly fewer complications observed in the short-term drainage group (31.1% vs. 52%; p = 0.02). We found that long-term preoperative drainage (unadjusted OR, 3.386; 95% CI, 1.507-7.606; p < 0.01) and periampullary carcinoma (unadjusted OR, 5.519; 95% CI, 1.722-17.685; p-value < 0.01) were independent risk factors for postoperative morbidity, based on the results of a multivariate regression model. The adjusted overall and recurrence-free survival did not differ between the groups (p = 0.12). CONCLUSION: PBD in patients scheduled for pancreatic surgery is associated with substantial perioperative morbidity. Our results indicate that patients who have undergone PBD should be operated on within 4 weeks after drainage.