Anatomic location and mechanism of hiatal hernia recurrence: a video-based assessment.

INTRODUCTION: Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates. METHODS: Retrospective chart review and video analysis were performed for all recurrent hiatal hernia operations performed by a single surgeon between January 2013 and April 2020. Hiatal recurrences were defined by anatomic quadrants. Recurrences on both left and right on either the anterior or posterior portion of the hiatus were simply classified as 'anterior' or 'posterior', respectively. Three or more quadrants were defined as circumferential. Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus. RESULTS: There were 130 patients to meet criteria. Median time to reoperation from previous hiatal repair was 60 months (IQR19.5-132). First-time recurrent repairs accounted for 74%, second time 18%, and three or more previous repairs for 8% of analyzed procedures. Mesh had been placed at the hiatus in a previous operation in 16%. All reoperative cases were completed laparoscopically. Video analysis revealed anterior recurrences were most common (67%), followed by circumferential (29%). There were two with left-anterior recurrence (1.5%), two posterior recurrence (1.5%), and one right-sided recurrence. The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. Neither the prior number of hiatal surgeries nor the presence of mesh at the time of reoperation correlated with anatomic recurrence location or mechanism. Reoperations in patients with hiatal disruption occurred after a shorter interval when compared to hiatal dilation. CONCLUSION: The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.

Sensors and Psychomotor Metrics: A Unique Opportunity to Close the Gap on Surgical Processes and Outcomes.

The surgical process remains elusive to many. This paper presents two independent empirical investigations where psychomotor skill metrics were used to quantify elements of the surgical process in a procedural context during surgical tasks in a simulated environment. The overarching goal of both investigations was to address the following hypothesis: Basic motion metrics can be used to quantify specific aspects of the surgical process including instrument autonomy, psychomotor efficiency, procedural readiness, and clinical errors. Electromagnetic motion tracking sensors were secured to surgical trainees' (N = 64) hands for both studies, and several motion metrics were investigated as a measure of surgical skill. The first study assessed performance during a bowel repair and laparoscopic ventral hernia (LVH) repair in comparison to a suturing board task. The second study assessed performance in a VR task in comparison to placement of a subclavian central line. The findings of the first study support our subhypothesis that motion metrics have a generalizable application to surgical skill by showing significant correlations in instrument autonomy and psychomotor efficiency during the suturing task and bowel repair (idle time: r = 0.46, p < 0.05; average velocity: r = 0.57, p < 0.05) and the suturing task and LVH repair (jerk magnitude: r = 0.36, p < 0.05; bimanual dexterity: r = 0.35, p < 0.05). In the second study, performance in VR (steering and jerkiness) correlated to clinical errors (r = 0.58, p < 0.05) and insertion time (r = 0.55, p < 0.05) in placement of a subclavian central line. Both gross (dexterity) and fine motor skills (steering) were found to be important as well as efficiency (i.e., idle time, duration, velocity) when seeking to understand the quality of surgical performance. Both studies support our hypotheses that basic motion metrics can be used to quantify specific aspects of the surgical process and that the use of different technologies and metrics are important for comprehensive investigations of surgical skill.

Screening surgical residents' laparoscopic skills using virtual reality tasks: Who needs more time in the sim lab?

BACKGROUND: This study investigated the possibility of using virtual reality perceptual-motor tasks as a screening tool for laparoscopic ability. We hypothesized that perceptual-motor skills assessed using virtual reality will correlate with the quality of simulated laparoscopic ventral hernia repair. MATERIALS AND METHODS: Surgical residents (N = 37), performed 2 virtual reality perceptual-motor tasks: (1) force matching and (2) target tracking. Participants also performed a laparoscopic ventral hernia repair on a simulator and final product quality score, and endoscopic visualization errors were calculated. Correlational analysis was performed to assess the relationship between performance on virtual reality tasks and laparoscopic ventral hernia repair. RESULTS: Residents with poor performance on force matching in virtual reality-"peak deflection" (r = -0.34, P < .05) and "summation distance" (r = -0.36, P < .05)-had lower final product quality scores. Likewise, poor performance in virtual reality-based target tracking-"path length" (r = -0.49, P < .05) and "maximum distance" (r = -0.37, P < .05)-correlated with a lower final product quality score. CONCLUSION: Our findings support the notion that virtual reality could be used as a screening tool for perceptual-motor skill. Trainees identified as having poor perceptual-motor skill can benefit from focused curricula, allowing them to hone personal areas of weakness and maximize technical skill.

Improving diagnosis in healthcare: Local versus national adoption of recommended guidelines for the clinical breast examination.

BACKGROUND: This study explores the long-term effectiveness of a newly developed clinical skills curriculum. METHODS: Students (N = 40) were exposed to a newly developed, simulation-based, clinical breast exam (CBE) curriculum. The same students returned one year later to perform the CBE and were compared to a convenience sample of medical students (N = 15) attending a national conferences. All students were given a clinical vignette and performed the CBE. CBE techniques were video recorded. Chi-squared tests were used to assess differences in CBE technique. RESULTS: Students exposed to a structured curriculum performed physical examination techniques more consistent with national guidelines than the random, national student sample. Structured curriculum students were more organized, likely to use two hands, a linear search pattern, and include the nipple-areolar complex during the CBE compared to national sample (p < 0.01). CONCLUSIONS: Students exposed to a structured skills curriculum more consistently performed the CBE according to national guidelines. The variability in technique compared with the national sample of students calls for major improvements in adoption and implementation of structured skills curricula.