The effect of warm-up on surgical performance: a systematic review.

BACKGROUND: The concept of warming-up before a performance has been accepted across many disciplines including sports and music. In contrast, it is uncommon for a surgeon to "warm-up" prior to operating. OBJECTIVE: To date, few studies from various specialties have attempted to answer this question whether warm-up improved the intraoperative performance of the surgeon. However, there has not been a systematic review of these studies. The aim of our systematic review is to assess the effect of warming-up preoperatively on the laparoscopic performance of the surgeon. METHODS: Pubmed and scopus were searched to identify all published prospective observational studies, which involved either residents, fellows or attending surgeons. We excluded case reports, reviews, non-English studies, and medical student participation. Study risk of bias were assessed regarding sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases, using a validated Cochrane Collaboration's tool. RESULTS: Out of 241 studies, 6 met the inclusion criteria. All included studies were randomized with half of them being randomized controlled studies and the rest randomized crossover studies. The total number of operative cases was 196, including 98 warm-up and 98 non warm-up. The total number of participants was 87, with the largest number in a single study being 38 and the average sample size of all studies was 14. All six studies assessed various aspects of laparoscopic surgical performances. Significant improvement in the intraoperative laparoscopic performance was observed with warming-up preoperatively in five out of six studies (p < 0.05). The sixth study failed to reach statistical significance (p > 0.05). CONCLUSION: Warming-up before an operative procedure improve a trainee's technical, cognitive, and psychomotor performance. Further studies are necessary to assess the ways in which warm-up could impact a surgeon's performance, and to identify the optimal timing and duration of warm-up prior to operating.

Preoperative warm-up the key to improved resident technique: a randomized study.

BACKGROUND: The ACGME has required that a skills lab be incorporated into the surgical residency curriculum. While the value of warm-up is generally accepted in other areas requiring complex motor skills, there is little evidence to support the benefits of warm-up prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period prior to operating impacts operative technique. METHODS: All general surgery residents and MIS fellows were included in this IRB-approved randomized study. Participants were randomized to either warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 min practice session in the simulation lab within 1 h of starting the case, using an FLS training box. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use of pre-procedure warm-up. The results of the questionnaire were analyzed using student's t test with p < 0.05 for significance. RESULTS: Pilot data were obtained after completing 40 cases that were randomized to warm-up (19) or no warm-up (21). There was a statistically significant improvement in depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03) for those randomized to warm-up. There was statistical improvement when we preformed a composite scoring of the attending evaluations for each of the Reznick (p = 0.008) and the Vassiliou (p = 0.01) global rating scales. CONCLUSIONS: Preoperative warm-up significantly improves depth perception, bimanual dexterity, and efficiency of movements, as well as improvement in composite scores as judged by the attending surgeon. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect that surgical performance can be enhanced through structured warm-up activities.

GERD Is Associated with Higher Long-Term Reoperation Rates After Bariatric Surgery.

BACKGROUND: Although bariatric surgery is a safe and effective treatment for morbid obesity, long-term reoperation remains a significant source of morbidity and mortality for the patient. METHODS: We performed a retrospective analysis of all patients undergoing laparoscopic gastric bypass (LGBP) or laparoscopic sleeve gastrectomy (LSG) surgeries at our institution between 2009 and 2013. Main outcome of interest was reoperation rate up to current date. Final logistic regression model included age, gender, BMI at time of operation, race (Caucasian vs African American), surgery time, length of stay, history of diabetes, history of gastroesophageal reflux disease (GERD), type of surgery, and readmission. RESULTS: A total of 533 patients underwent either LGBP or LSG surgery between 2009 and 2013. Overall reoperation rate was 9.0% and mean follow-up was 43.9 months (median 45). When stratified by race, preoperative GERD in Caucasians was associated with a significant 2.2-fold increased risk of reoperation (OR 2.2, 95% CI 1.0­4.8, P = .043). GERD in African Americans had a small nonsignificant increased risk. Other significant predictors included length of stay and readmission (OR 2.1, P = 0.029; OR 5.0, P < 0.000). CONCLUSION: Preoperative GERD in Caucasian bariatric patients is associated with a higher risk of reoperation. Lengthy hospital stay and readmission within 30 days of laparoscopic bariatric surgery are independent predictors of higher reoperation rates.