Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos

Introduction

Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning.

Objective

We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation.

Material and methods

Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12 h in animal models, and 4 h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work.

Results

Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was > 10 cases/month in 19%, and < 5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach.

Conclusions

Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.     

Evaluation of a blended learning surgical skills course for rural surgeons

Background

Rural surgeons have unique learning needs not easily met by traditional continuing medical education courses.

Methods

A multidisciplinary team developed and implemented a skills curriculum focused on leadership and communication, advanced endoscopy, emergency urology, emergency gynecology, facial plastic surgery, ultrasound, and management of fingertip amputations.

Results

Twenty-five of 30 (89%) rural surgeons who completed a follow-up course evaluation reported that the knowledge acquired during the course had improved their practice and/or the quality of patient care, particularly by refining commonly used skills and expanding the care options they could offer to their patients. The surgeons reported incorporating changes in their communication and interaction with colleagues.

Conclusions

This course was successful, from participants' perspectives, in providing hands-on mentored training for a variety of skills that reflect the broad scope of practice of surgeons in rural areas. Attendees felt that their participation resulted in important behavior and practice changes.     

Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States

Background context

There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States.

Purpose

To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation.

Study design

Electronic survey.

Patient sample

An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States.

Outcome measures

The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups.

Methods

A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons.

Results

Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume.

Conclusions

Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system.     

Challenges of training and delivery of pediatric surgical services in Africa

Background

The practice of pediatric surgery in Africa presents multiple challenges. This report presents an overview of problems encountered in the training of pediatric surgeons as well as the delivery of pediatric surgical services in Africa.

Methods

A returned structured self-administered questionnaire sent to pediatric surgeons practicing in Africa was reviewed and analyzed using SPSS version 11.5 (SPSS, Chicago, IL).

Results

Forty-nine (57%) of 86 questionnaires were returned from 8 countries. Great variability in the requirements and training of pediatric surgeons, even within the same country, was found. Many surgical colleges are responsible for standardization and board certification of pediatric surgeons across Africa. There were 6 (12%) centers that train middle level manpower. Twenty-six (53%) participants have 1 to 2 trainees, whereas 22 (45%) have irregular or no trainee. A pediatric surgical trainee needs 2 to 4 (median, 2) years of training in general surgery to be accepted for training in pediatric surgery, and it takes a trainee between 2 to 4 (median, 3) years to complete training as a pediatric surgeon in the countries surveyed. The number of pediatric surgeons per million populations is lowest in Malawi (0.06) and highest in Egypt (1.5). Problems facing adequate delivery of pediatric surgical services enumerated by participants included poor facilities, lack of support laboratory facilities, shortage of manpower, late presentation, and poverty.

Conclusion

The training of pediatric surgical manpower in some African countries revealed great variability in training with multiple challenges. Delivery of pediatric surgical services in Africa presents problems like severe manpower shortage, high pediatric surgeon workload, and poor facilities. Standardization of pediatric surgery training across the continent is advocated, and the problems of delivery of pediatric surgical services need to be addressed urgently, not only by health care planners in Africa but by the international community and donor agencies, if the African child is to have access to essential pediatric surgical services like his or her counterpart in other developed parts of the world.     

A survey-based assessment of the Canadian pediatric surgery workforce

Background

There is significant lack of information regarding the Canadian pediatric surgery workforce.

Methods

An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.

Results

The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.

Conclusions

The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.     

Palliative and end-of-life care training during the surgical clerkship

Background

In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine.

Materials and methods

In the 2007–08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback.

Results

All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024).

Conclusions

Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, “Conducting a Family Conference” proved to be the most challenging.     

Reliable assessment of general surgeons' non-technical skills based on video-recordings of patient simulated scenarios

Background

Nontechnical skills are essential for safe and efficient surgery. The aim of this study was to evaluate the reliability of an assessment tool for surgeons' nontechnical skills, Non-Technical Skills for Surgeons dk (NOTSSdk), and the effect of rater training.

Methods

A 1-day course was conducted for 15 general surgeons in which they rated surgeons' nontechnical skills in 9 video recordings of scenarios simulating real intraoperative situations. Data were gathered from 2 sessions separated by a 4-hour training session.

Results

Interrater reliability was high for both pretraining ratings (Cronbach's α = .97) and posttraining ratings (Cronbach's α = .98). There was no statistically significant development in assessment skills. The D study showed that 2 untrained raters or 1 trained rater was needed to obtain generalizability coefficients >.80.

Conclusions

The high pretraining interrater reliability indicates that videos were easy to rate and Non-Technical Skills for Surgeons dk easy to use. This implies that Non-Technical Skills for Surgeons dk (NOTSSdk) could be an important tool in surgical training, potentially improving safety and quality for surgical patients.     

Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals

Background

A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.

Methods

A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.

Results

Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.

Conclusion

Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.     

The general surgery workforce shortage is worse when assessed at county level

Background

Multiple studies have documented a significant decrease in the general surgery workforce in the United States, both rural and urban, for the past 3 decades. This 11-year study evaluates the Texas general surgery workforce at both the state and local level in 2002 and 2012.

Methods

Data were obtained from the Texas Medical Board, the United States Census Bureau/Texas State Library and Archives Commission, and the Texas Department of State Health Services for 2002 and 2012. A benchmark target of 7 general surgeons per 100,000 population was used.

Results

During the study period, the Texas population increased 21%, and actively practicing physicians increased 44%. All surgical specialists increased by 26%. General surgeons increased 4%; however, the number of general surgeons per 100,000 population decreased 14% (from 6.7 to 5.8/10⁵). Using the total Texas population for 2012, an additional 329 general surgeons are needed by benchmark standards. However, when analyzed by individual county population, 449 additional general surgeons are needed in the individual counties. These effects were greater in the nonmetropolitan areas of Texas where per capita general surgeons decreased by 21%.

Conclusions

The absolute increase in Texas general surgeons over the past decade has not kept pace with an increase in the Texas population. The general surgery workforce deficit based on the Texas state population underestimates the local workforce shortage, particularly in the nonmetropolitan areas of Texas.     

Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center

Background

Previous studies have shown that complications and biochemical recurrence rates after radical prostatectomy (RP) vary between different surgeons to a greater extent than might be expected by chance. Data on urinary and erectile outcomes, however, are lacking.

Objective

In this study, we examined whether between-surgeon variation, known as heterogeneity, exists for urinary and erectile outcomes after RP.

Design, setting, and participants

Our study consisted of 1910 RP patients who were treated by 1 of 11 surgeons between January 1999 and July 2007.

Intervention

All patients underwent RP at Memorial Sloan-Kettering Cancer Center.

Measurements

Patients were evaluated for functional outcome 1 yr after surgery. Multivariable random effects models were used to evaluate the heterogeneity in erectile or urinary outcome between surgeons, after adjustment for case mix (age, prostate-specific antigen, pathologic stage and grade, comorbidities) and year of surgery.

Results and limitations

We found significant heterogeneity in functional outcomes after RP (p < 0.001 for both urinary and erectile function). Four surgeons had adjusted rates of full continence <75%, whereas three had rates >85%. For erectile function, two surgeons in our series had adjusted rates <20%; another two had rates >45%. We found some evidence suggesting that surgeons’ erectile and urinary outcomes were correlated. Contrary to the hypothesis that surgeons “trade off” functional outcomes and cancer control, better rates of functional preservation were associated with lower biochemical recurrence rates.

Conclusions

A patient's likelihood of recovering erectile and urinary function may differ depending on which of two surgeons performs his RP. Functional preservation does not appear to come at the expense of cancer control; rather, both are related to surgical quality.     

Resultados de una encuesta nacional sobre el cierre de la pared abdominal

Objective

To assess knowledge on the abdominal wall closure through a surgeon cohort survey.

Methods

A twenty question individual questionnaire on laparotomy in elective surgery.

Results

A total of 131 surgeons from seven hospitals responded (72% specialists and 28% in training). 71% of respondents estimated the frequency of incisional hernia to be higher than 15% and 54% considered the technique to be the most significant risk factor. 85% considered midline laparotomy closed with slow absorbable suture (57%) in a single layer (66%) to be the most appropriate technique. 67% believed retention sutures to be the appropriate prevention technique. 50% did not know or could not apply the 4:1 technique. 87% considered that an incisional hernia can be prevented and that the technique is the most important factor on which to act. 84% believed that a prosthesis can prevent the occurrence of incisional hernia, whereas 40% of respondents never use it and only 38% use it in patients at risk. On comparing surveys between specialists and residents, significant differences appeared in terms of a better understanding of the theoretical technical aspects in trainee surgeons.

Conclusions

Although the results show an adequate understanding of the epidemiology and risk factors for development of incisional hernia, training and consensus measures are likely to be introduced in some basic technical aspects in order to improve results in laparotomy closure.     

Effect of alcohol on surgical dexterity after a night of moderate alcohol intake

Background

Alcohol misuse is commonplace among health professionals. The effects of alcohol on cognition and dexterity have been shown up to 14 hours after alcohol intake. The aerospace industry has restrictions on alcohol intake, and there is pressure for the health care industry to do the same. Few studies have addressed the lingering impact alcohol has on surgical performance, and none have measured surgical dexterity using well-established Fundamentals of Laparoscopic Surgery benchmarks.

Methods

Twenty-seven surgeons participated in this study: 11 attending surgeons, 2 fellows, and 14 resident surgeons. Three Fundamentals of Laparoscopic Surgery tasks measured surgical dexterity: peg transfer, pattern cutting, and intracorporeal suturing. Performance on these tasks was measured before alcohol intake and the morning after a night of social drinking. Alcohol levels were measured via breathalyzer 20 minutes after completion of drinking and the following morning before testing. Time and accuracy were compared.

Results

The mean blood alcohol level was .076 mg/100 mL blood. Times for peg transfer, pattern cutting, and intracorporeal suturing showed no differences. Accuracy in pattern cutting was not different, but accuracy for intracorporeal suturing was significantly worse the morning after alcohol intake.

Conclusions

The morning after moderate alcohol intake, the time to complete Fundamentals of Laparoscopic Surgery tasks was unchanged, but accuracy was worse.     

Pediatric surgeons’ attitudes toward regionalization of neonatal surgical care

Background/Purpose

Research has suggested that high-risk pediatric surgical patients have better outcomes when treated in resource-rich children’s environments. Surgical neonates are a particularly high-risk population and some suggest that regionalization might be a strategy to improve clinical outcomes in neonatal surgical patients. We conducted a national survey of pediatric surgeons in the United States to explore their attitudes toward regionalization of neonatal surgical care.

Methods

Members of the American Pediatric Surgical Association were asked to participate in an anonymous online survey to assess both attitudes toward regionalization, as well as perceptions of the importance of various resources in providing optimal care for surgical neonates.

Results

Overall, 56.2% of participants favored regionalization. Surgeons whose practice was part of a training program tended to favor regionalization more, as did those from larger group practices and those who practiced at free-standing children’s hospital. In addition, surgeons from larger groups and those involved with training programs more strongly favored the premise that a higher level of resource commitment should be available to treat surgical neonates.

Conclusions

The impact of any national strategy to improve neonatal surgical outcomes will be large and multi-faceted. While the majority of pediatric surgeons favor regionalization, our findings demonstrate variation in this view and highlight the necessity for surgeon involvement and education that will be critical in this effort.     

Efficacy of cognitive feedback in improving operative risk estimation

Background

Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships.

Methods

Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set.

Results

Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further.

Conclusions

Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making.     

When surgeons decide to become surgeons: new opportunities for surgical education

Background

When surgeons decide to become surgeons has important implications. If the decision is made prior to or early in medical school, surgical education can be more focused on surgical diseases and resident skills.

Methods

To determine when surgeons – compared with their nonsurgical colleagues – decide on their medical path, residents in surgery, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and emergency medicine were surveyed. Timing of residency choice, demographic data, personal goals, and reason for residency choice were queried.

Results

A total of 234 residents responded (53 surgical residents). Sixty-two percent of surgeons reported that they were “fairly certain” of surgery before medical school, 13% decided during their preclinical years, and 25% decided during their clerkship years. This compares with an aggregate 40%, 7%, and 54%, respectively, for the other 5 residency specialties. These differences were statistically significant (P = .001). When the 234 residents were asked about their primary motivation for choosing their field, 51% pointed to expected job satisfaction and 44% to intellectual curiosity, and only 3% mentioned lifestyle, prestige, or income.

Conclusions

General surgery residents decide on surgery earlier than residents in other programs. This may be advantageous, resulting in fast-tracking of these medical students in acquiring surgical knowledge, undertaking surgical research, and early identification for surgical residency programs. Surgical training in the era of the 80-hour work week could be enhanced if medical students bring much deeper knowledge of surgery to their first day of residency.     

Surgical resident perspective on deceased donor organ procurement

Background

Deceased donor organ procurement provides unparalleled opportunity for surgical residents with extensive surgical exposure. We hypothesize that surgical residents regard organ donation positively and organ procurement enhances their education.

Methods

We conducted an institutional review board approved anonymous national survey to evaluate organ procurement experiences and attitudes of general surgical residents.

Results

Three hundred ninety-seven residents representing all postgraduate years responded, with 97% completion rate. Organ procurement increased with training level (92% seniors vs 53% interns). Over 85% agree organ procurement is a good educational and operative experience, and 73% believe that it will benefit their future surgical career. About 68% agree that organ procurement provided knowledge of anatomy and exposures; under 10% felt organ procurement could be duplicated with simulation. Presence of transplant program did not affect attitudes or experience. Eighty-eight percent women versus77% men plan to donate their own organs.

Conclusion

Results indicate that surgical residents value organ procurement, and it remains an essential encounter that applies to general surgery.     

Impact of podiatry resident experience level in hallux valgus surgery on postoperative outcomes

Background

Despite modern advancements in transosseous fixation and operative technique, hallux valgus (i.e., bunion) surgery is still associated with a higher than usual amount of patient dissatisfaction and is generally recognized as a complex and nuanced procedure requiring precise osseous and capsulotendon balancing. It stands to reason then that familiarity and skill level of trainee surgeons might impact surgical outcomes in this surgery. The aim of this study was to determine whether podiatry resident experience level influences midterm outcomes in hallux valgus surgery (HVS).

Methods

Consecutive adults who underwent isolated HVS via distal metatarsal osteotomy at a single US metropolitan teaching hospital from January 2004 to January 2009 were contacted and asked to complete a validated outcome measure of foot health (Manchester–Oxford Foot Questionnaire) regarding their operated foot. Resident experience level was quantified using the surgical logs for the primary resident of record at the time of each case. Associations were assessed using linear and logistic regression analyses.

Results

A total of 102 adult patients (n = 102 feet) agreed to participate with a mean age of 46.8 years (standard deviation 13.1, range 18–71) and average length of follow-up 6.2 y (standard deviation 1.4, range 3.6–8.6). Level of trainee experience was not associated with postoperative outcomes in either the univariate (odds ratio 0.99 [95% confidence interval, 0.98–1.01], P = 0.827) or multivariate analyses (odds ratio 1.00 [95% confidence interval, 0.97–1.02], P = 0.907).

Conclusions

We conclude that podiatry resident level of experience in HVS does not contribute appreciably to postoperative clinical outcomes.     

International surgical clerkship rotation: perceptions and academic performance

Background

Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship.

Methods

A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers.

Results

Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions.Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement.Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant.

Conclusions

This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.     

Jack Barney award: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons

Background

Fatigue and sleep deprivation and their effects on surgical proficiency have been actively researched areas. Past studies that have focused solely on residents have provided an important insight into how fatigue affects residents' ability to perform. This study aims to quantify the effect of fatigue on attending surgeons.

Methods

To quantify the effect of fatigue on psychomotor and cognitive skills of surgical residents and attending surgeons, visiohaptic simulations were created to mimic realistic interactions.

Results

Both groups showed a significant decrement in proficiency measures postcall. When tasks were separated based on psychomotor versus cognitive-dominated skills, attending surgeons made 25% fewer (P < .05) cognitive errors than residents postcall. Psychomotor skills were equally affected in both groups.

Conclusions

Call-associated fatigue is associated with increased error rates in the cognitive skill domain, although less so in attending surgeons compared with their resident counterparts.