Remote telepresence surgery: the Canadian experience

On 28 February 2003, the world’s first telerobotic surgical service was established between St. Joseph’s Healthcare Hamilton, a teaching hospital affiliated with McMaster University, and North Bay General Hospital, a community hospital 400 km away. The service was designed to provide telerobotic surgery and assistance by expert surgeons to local surgeons in North Bay, and to improve the range and quality of advanced laparoscopic surgeries offered locally. The two surgeons have collaboratively performed 22 remote telepresence surgeries including laparoscopic fundoplications, laparoscopic colon resections, and laparoscopic inguinal hernia repairs. This article describes the important lessons learned, including the telecommunication requirements, the impact from lack of haptic feedback, surgeons’ adaptation to latency, and ethical and medicolegal issues. This is currently the largest clinical experience with assisted robotic telepresence surgery (ARTS) in the world, and the lessons learned will help guide the future design and development of telesurgical robotic platforms. It also will guide the establishment of telesurgical networks connecting various centers in the world, allowing for rapid and safe dissemination of new surgical techniques.     

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.     

Vascular surgery training in general surgery residency programs: the Canadian experience

OBJECTIVES: Vascular surgery is traditionally considered a component of general surgery. There is growing evidence of improved patient outcome related to surgeon volume and vascular certification status. The American Board of Surgery in the United States, as well as until recently the Royal College of Physicians and Surgeons in Canada, requires that vascular surgery be considered an essential content area of general surgery training. This requirement is controversial. The purpose of this study was to describe experience and perceived competence in common vascular surgery procedures during general surgery residency training in Canada. METHODS: This web-based survey was conducted between January and June 2002. General surgery program directors (GSPDs), vascular surgeons involved in general surgery training programs (VSs), and senior general surgery residents (SRs) from the 13 English-speaking general surgery programs in Canada were surveyed. Questions were asked regarding which vascular surgery procedures are appropriate for general surgeons to perform, which procedures SRs are trained to perform, and which procedures SR intend to perform. RESULTS: The response rate was 62% for GSPDs, 57% for VSs, and 45% for SRs. Overall, 49% of SRs did not intend to perform any vascular procedures after training. GSPDs, VSs, and SRs indicated that most SRs should be and are trained to perform varicose vein surgery, leg amputation, and femoral embolectomy (P >.05). In addition, GSPDs, VSs, and SRs indicated that SRs should not be and are not trained to perform infrainguinal bypass grafting, carotid endarterectomy, or abdominal aortic aneurysm (AAA) repair (P >.05). There were significant differences with respect to ruptured AAA repair: 49% of SRs, 25% of PDs, and only 12% of VSs believe that general surgeons should be trained to perform ruptured AAA repair (P <.05). Overall, 76% of VSs believe SRs receive too little vascular training. CONCLUSION: There is similarity between GSPDs, VSs, and SRs with respect to vascular surgery training in Canadian general surgery programs. Vascular surgery training cannot be considered a component of general surgery. More rotations or fellowship training is required to become competent in management of common vascular surgery procedures. Perhaps this level of competence should not be an objective of general surgery training.     

A survey of Canadian general surgery residents' interest in international surgery

Objective

This survey of Canadian general surgery residents was designed to determine their interest level, past experiences and awareness of opportunities in the field of international surgery.

Methods

A web-based national survey in both French and English was sent to all Canadian general surgery residents. This survey comprised 24 questions regarding demographics, education, previous international experience, interest level and perceived opportunities in international surgery.

Results

A 27% response rate revealed a high level of interest in international surgery among Canadian general surgery residents but a low level of awareness of the opportunities and relevant organizations.

Conclusion

Further initiatives are needed to increase international surgery awareness and opportunities among general surgery residents.     

Canadian human resource needs in vascular surgery

Objective

To outline the distribution of vascular surgeons in Canada and to determine the present and future human resource needs in vascular surgery practice in Canada.

Design

Voluntary questionnaires sent to all members of the Canadian Society for Vascular Surgery (CSVS), the administrators of hospitals in Canada with more than 100 beds, and interrogation of the membership database of the CSVS.

Main outcome measures

The perceived present and future needs for fulltime and part-time vascular surgeons, determined by a variety of methods.

Participants

One hundred and forty active members of the CSVS and administrators of 120 hospitals.

Main results

From the CSVS members 62 responses were received from those residing in Canada, revealing 47 fulltime vascular (more than 75% of the practice) surgeons working with 0 to 5 colleagues (mean 1.8 [SD 1.3]). Fifteen responding surgeons combined the practice of vascular surgery with another specialty. Perceived immediate needs were 24 surgeons, with 42 required in 4.8 (1.8) years. Of 120 hospitals offering vascular surgery services, 90 stated that they met the needs of their community; however, additional immediate manpower requirements totalled 27 surgeons. Hospital administrators predicted a need of 55 additional vascular surgeons in a mean of 5.5 (4.6) years. Over 85% of hospitals stated that they had the resources to support the currently practising surgeons and their immediately required additions.

Conclusions

Prediction of the need for additional vascular surgeons should be based on an estimated retirement age of 65 years, with an adjustment for the increasing percentage of the Canadian population reaching the age of 60 years. All methodologies used in this study predict the need for additional human resources in vascular surgery. The need for continued training of new vascular surgeons is apparent, but the optimal number of trainees per year is less clear.     

Status of robotic-assisted surgery among Canadian urology residents

Background

Robotic-assisted surgery (RAS) has been rapidly adopted in urology, especially in the United States. Although less prevalent in Canada, RAS is a growing and controversial field that has implications for resident training. We report on the status and perception of RAS among Canadian urology residents.

Methods:

All Canadian urology residents from anglophone programs were contacted by email and asked to participate in an online survey. Current resident exposure to, and perception of, RAS was assessed.

Results:

Of the residents contacted (n = 128), 50 (39%) completed the survey. Of the respondents, 52% have been involved in RAS. Those who have not been involved in RAS express lower interest and lesser knowledge of RAS. Ninety-two percent of respondents feel the use of RAS will increase, although only 29% feel this is feasible in Canada. Just 24% and 36% feel RAS to be superior to open and laparoscopic techniques, respectively. Sixty-eight percent of residents in programs with a robot viewed it as detrimental to training, whereas 81% of residents in programs without one viewed its absence to either have no impact, or even be beneficial. Both groups expressed a desire for more experience with RAS.

Conclusion:

The resident experience with respect to RAS is mixed. Overall, residents view RAS as an expanding field with potentially negative impacts on their present training, although they appear to desire the acquisition of more experience in RAS. We plan to monitor the evolution of these perceptions over next four years.     

Current perioperative practice in Canadian vascular surgery

Background

The Enhanced Recovery After Surgery (ERAS) Society has set out to improve patient recovery by developing evidence-based perioperative practices. Many institutions and other specialties have begun to apply their principles with great success; however, ERAS principles focus mostly on general surgery, and their applicability to other specialties, such as vascular surgery, is less clear. We sought to investigate the current standard of perioperative care in Canadian vascular surgery by assessing surgeons’ perceptions of evidence supporting ERAS practices, identifying barriers to aligning them and identifying aspects of perioperative care that require research specific to vascular surgery before they could be broadly applied.

Methods

We administered an online survey with 26 questions to all Canadian Society for Vascular Surgery members.

Results

Respondents varied largely in perioperative practice, most notably in the use of nasogastric tubes, Foley catheters and neck drains. Familiarity with supporting evidence was poor. Approximately half (44%) of respondents were not familiar with contrary evidence, while those who were often perceived institutional barriers to change. Finally, one-third (30%) of respondents felt that relevant evidence did not exist to support changing their practice.

Conclusion

The variability of perioperative practice in Canadian vascular surgery is likely due to multiple factors, including a lack of specific evidence. Further research in areas of perioperative vascular care where the current standard of practice varies most greatly may help improve recovery after vascular surgery in Canada over simply adopting existing ERAS principles.     

Canadian general surgery: alive and well

General surgery in Canada is alive and well because general surgeons remain versatile and adaptable. If this were not the case, the specialty of general surgery would go the way of the dinosaur. The continuing evolution of general surgery can only be maintained by reviewing the following: (a) training; (b) continuing education; (c) maintenance of competence; (d) manpower and economic aspects; and (e) interaction of general surgeons with other surgeons and specialties. The Canadian Association of General Surgeons will continue to play a vital role in maintaining liaison between all types of general surgeons across the country and help, in any way possible, to support the ever-changing face of general surgery.     

Training general surgery residents in pediatric surgery: A Canadian survey

BACKGROUND/PURPOSE: The training of general surgeons in pediatric surgery is an important educational role of pediatric surgeons (PS). The authored surveyed this training process and the related expectations and perceptions of competence. METHODS: The authors surveyed all practicing members of the Canadian Association of Paediatric Surgeons (CAPS) in Canada, all general surgery program directors (PD), and all final year general surgery residents (GS). Questions included exposure to pediatric surgery, expected and perceived competence in managing common pediatric general surgical problems, and trainee practice intentions. RESULTS: Response rate to date was 51% from PS, 69% from PD, and 19% from GS. Sixty-seven percent of PS considered the exposure to pediatric surgery satisfactory, yet only 1 of 7 residents planning on pursuing general surgery felt adequately prepared. Trainees were expected to be competent in the conditions polled by 65% of PS and 74% of PD, yet only 38% of the trainees actually felt competent in them. The largest discrepancies were found for infant hernia, newborn colostomy, and cryptorchidism. Presence of a fellowship program and size of training program had no impact on perceived competence. CONCLUSIONS: Training of general surgeons in pediatric surgery varies across Canadian programs. Perceived resident competence often lags behind program and faculty expectations. These data can be used for directing educational priorities in general surgery programs.     

The contribution of Canadian anaesthetists to the evolution of cardiac surgery

Purpose

There have been great improvements in the management of patients with heart disease over the past 50 yr much of which has been due to the development of surgical procedures for the correction of acquired and congenital cardiac abnormalities. A great deal has been written about the surgeons and the innovative procedures they developed. They were undoubtedly courageous, imaginative, knowledgeable and skilful. Little is written about the anaesthetists who often worked in the laboratory with the surgeons and provided anaesthesia for patients having this surgery which, in the early days, was experimental. The purpose of this article is to present the contributions made by Canadian anaesthetists to the evolution of cardiac surgery.

Principal findings

The contributions have been important over five clearly discernable eras and have been identified through publications. Canadian anaesthetists wrote about their experience giving anaesthesia for mitral commissurotomy, relief of pulmonic stenosis, ligation of patent ductus arteriosus, resection of aortic coarclation, correction of simple congenital heart defects under hypothermia and myocardial revascularization. When open heart surgery was introduced, Canadian anaesthetists working both in the United States and Canada were amongst the first to publish on surgery supported by cardiopulmonary bypass and anaesthesia for these procedures.

Conclusion

An analysis of the literature and personal, verbal and written communications with anaesthetists who experienced the trials and tribulations of anaesthesia for these early surgical procedures clearly indicates that Canadians were at the forefront in advancing anaesthesia for cardiac surgery.