Effects of Fatigue on Residents' Performance in Laparoscopy

Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes

BACKGROUND AND OBJECTIVES

Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes.

METHODS

This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 pm and 7 am, with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 pm and 7 am, with other times classified as on-hours.

RESULTS

This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes.

CONCLUSION

Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.

Design and evaluation of a smart passive dynamic arm support for robotic-assisted laparoscopic surgery

Surgeons performing robotic-assisted laparoscopic surgery experience physical stress and overuse of shoulder muscles due to sub-optimal arm support during surgery. The objective is to present a novel design and prototype of a dynamic arm support for robotic laparoscopic surgery to evaluate its ergonomics and performance on the AdLap-VR simulation training device. The prototype was designed using the mechanical engineering design process: Technical requirements, concept creation, concept selection, 3D-design and built of the prototype. A crossover study was performed on a marble sorting task on the AdLap-VR. The first group performed four trials without the arm support, followed by four trials with the arm support, and the other group executed the sequence vice versa. The performance parameters used were time to complete (s), path length (mm), and the number of collisions. Afterward, the participants filled out a questionnaire on the ergonomic experience regarding both situations. 20 students executed 160 performed trials on the AdLap-VR Significant decreases in the subjective comfort parameters mental demand, physical demand, effort and frustration were observed as a result of introducing the novel arm support. Significant decreases in the objective performance parameters path length and the number of collisions were also observed during the tests. The newly developed dynamic arm support was found to improve comfort and enhance performance through increased stability on the robotic surgery skills simulator AdLap-VR.

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

Comparison of the Time and Accuracy of Intraoral Scans Performed by Dentists, Nurses, Postgraduates, and Undergraduates

OBJECTIVE

This study aimed to assess the scanning time (ST) and accuracy of 10 repeated upper and lower dentition scans by four groups of operators with different professional backgrounds.

METHODS

There were a total of 32 participants, including dentists, nurses, postgraduates, and undergraduates (n=8). They received the same training about intraoral scanning and then performed 10 repeat scans on the plaster maxillary and mandibular dentition models in a manikin head, with the first five scans being the T1 phase and the last five scans being the T2 phase. Each ST was recorded. Trueness and precision were evaluated by root mean square (RMS) value gained from alignments of corresponding virtual models. For statistical analysis, the paired-sample t-tests, one-way ANOVA, and Pearson correlation tests were employed (α=0.05).

RESULTS

Limiting the comparison in scan phase and scan target the sequence of STs for the four groups was the same (p<0.05), by which undergraduates, postgraduates, nurses, and dentists were in descending order. Undergraduates gained the best precision, followed by postgraduates, dentists, and nurses, in both maxillary and mandibular scanning (p<0.05). Compared with corresponding items of the T1 phase, the trueness of the T2 phase was much higher (p<0.05), while the ST of the T2 phase was much shorter (p<0.05).

CONCLUSIONS

The operator's professional background affects the precision and scanning time but not the trueness. Most dental personnel have good access to the intraoral scanner. As the number of scans increased, the accuracy and scanning efficiency also improved.

A Polysomnographic Study of Effects of Sleep Deprivation on Novice and Senior Surgeons during Simulated Vitreoretinal Surgery

PURPOSE

To assess the impact of a 3-hour polysomnography (PSG)-recorded night of sleep deprivation on next-morning simulated microsurgical skills among vitreoretinal (VR) surgeons with different levels of surgical experience and associate the sleep parameters obtained by PSG with Eyesi-generated performance.

DESIGN

Self-controlled cohort study.

PARTICIPANTS

Eleven junior VR surgery fellows with < 2 years of surgical experience and 11 senior surgeons with > 10 years of surgical practice.

METHODS

Surgical performance was assessed at 7am after a 3-hour sleep-deprived night using the Eyesi simulator and compared with each subject's baseline performance.

MAIN OUTCOME MEASURES

Changes in Eyesi-generated score (0-700, worst to best), time for task completion (minutes), tremor-specific score (0-100, worst to best), and out-of-tolerance tremor percentage. Polysomnography was recorded during sleep deprivation.

RESULTS

Novice surgeons had worse simulated surgical performance after sleep deprivation compared with self-controlled baseline dexterity in the total score (559.1 ± 39.3 vs. 593.8 ± 31.7; P = 0.041), time for task completion (13.59 ± 3.87 minutes vs. 10.96 ± 1.95 minutes; P = 0.027), tremor-specific score (53.8 ± 19.7 vs. 70.0 ± 15.3; P = 0.031), and out-of-tolerance tremor (37.7% ± 11.9% vs. 28.0% ± 9.2%; P = 0.031), whereas no performance differences were detected in those parameters among the senior surgeons before and after sleep deprivation (P ≥ 0.05). Time for task completion increased by 26% (P = 0.048) in the post-sleep deprivation simulation sessions for all participants with a high apnea-hypopnea index (AHI) and by 37% (P = 0.008) among surgeons with fragmented sleep compared with those with normal AHI and < 10 arousals per hour, respectively. Fragmented sleep was the only polysomnographic parameter associated with a worse Eyesi-generated score, with a 10% (P = 0.005) decrease the following morning.

CONCLUSIONS

This study detected impaired simulated surgical dexterity among novice surgeons after acute sleep deprivation, whereas senior surgeons maintained their surgical performance, suggesting that the impact of poor sleep quality on surgical skills is offset by increased experience. When considering the 2 study groups together, sleep fragmentation and AHI were associated with jeopardized surgical performance after sleep deprivation.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Regulating effect of virtual reality restorative environment on prefrontal cortex dysfunction after night shifts in medical staff: an fNIRS study protocol for a randomized controlled trial in Dalian, China

BACKGROUND

Night shift work-related disturbed biological rhythm and insufficient sleep affect the functioning of brain activity and thus impair cognitive performance and mood state, which potentially leads to negative and even devastating results for both individuals and patients. A virtual reality (VR)-based restorative environment has shown to be an effective new technique to reduce stress and improve cognitive performance, but little is known about its mechanism of improving neuronal activity and connectivity.

METHODS

This is a randomized, controlled, single-center clinical trial. A total of 140 medical staff will be enrolled and randomized in a 1:1 allocation to either the VR immersion group (intervention group) or the control group. In the morning after the night shift, the participants in the intervention group will watch 360° panoramic videos of immersive VR natural restorative environments for 10 min, while the participants in the control group will just rest for 10 min. Assessments of abbreviated Profile of Mood States Questionnaire (POMS) and verbal fluency task (VFT) performances, as well as oxygenated hemoglobin (oxy-Hb) and deoxygenated hemoglobin (deoxy-Hb) and total hemoglobin concentration acquired by functional near-infrared spectroscopy (fNIRS) will be performed at baseline (day work), the morning after night shift but before the intervention (previous) and after intervention (post). Data collected after a night shift will be compared to baseline performance as well as between the two groups.

DISCUSSION

This trial will investigate the effects of the night shift and VR-based restorative environment intervention on mood, cognitive performance, and neuronal activity and connectivity. A positive result in this trial could encourage hospitals to apply VR technology to reduce physical and mental dysfunction during of night shifts among medical staff in every department. Furthermore, the findings from this study will contribute to understanding the underlying neuromodulation mechanisms of how restorative environments influence mood and cognition.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200064769 . Registered on 17 October 2022.

Comparison of nighttime and daytime operation on outcomes of supracondylar humeral fractures: A prospective observational study

Supracondylar humeral fractures are seen in children and treatment is usually closed reduction and percutaneous pinning (CRPP). This surgery can be performed at night, depending on its urgency. Fatigue and sleep deprivation can impact performance of doctors during night shifts. The purpose of this study is to investigate the association between night shifts postoperative morbidity and mortality of supracondylar fracture operations compared to daytime procedures. This prospective observational study included 94 patients who were aged 5 to 12 years with ASA I to III who had supracondylar humeral fractures, underwent CRPP under general anesthesia. Patients were stratified by the time of surgery using time of induction of anesthesia as the starting time of the procedure, into 2 groups: day (07:30 am-06:29 pm) and night (06:30 pm-07:29 am). In total, 82 patients completed the study: 43 in Group Day and 39 in Group Night. The operation duration in Group Night (114.66 ± 29.46 minutes) was significantly longer than in Group Day (84.32 ± 25.9 minutes) (P = .0001). Operation duration (OR: 0.007; P = .0001) and morbidities (OR: 0.417; P = .035) were independent risk factors in Group Night. Children who had supracondylar humeral fractures, undergoing urgent CRPP surgery, in-hospital mortality was associated with the time of day at which the procedure was performed. Patient safety is critically important for pediatric traumatic patient population. Therefore, we suggested to increase the number of healthcare workers and improve the education and experience of young doctors during night shifts.

Sleep deprivation among surgical residents: Does it affect performance while practising a laparoscopic intestinal anastomosis?

INTRODUCTION

To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis.

METHODS

A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches.

RESULTS

402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters.

CONCLUSIONS

Fatigue increases the risk of leakage and the time to do the exercise.

Biomathematical Modeling Predicts Fatigue Risk in General Surgery Residents

OBJECTIVE

To assess resident fatigue risk using objective and predicted sleep data in a biomathematical model of fatigue.

DESIGN

8-weeks of sleep data and shift schedules from 2019 for 24 surgical residents were assessed with a biomathematical model to predict performance ("effectiveness").

SETTING

Greater Washington, DC area hospitals RESULTS: As shift lengths increased, effectiveness scores decreased and the time spent below criterion increased. Additionally, 11.13% of time on shift was below the effectiveness criterion and 42.7% of shifts carried excess sleep debt. Sleep prediction was similar to actual sleep, and both predicted similar performance (p ≤ 0.001).

CONCLUSIONS

Surgical resident sleep and shift patterns may create fatigue risk. Biomathematical modeling can aid the prediction of resident sleep patterns and performance. This approach provides an important tool to help educators in creating work-schedules that minimize fatigue risk.

Sleepy Surgeons: A Multi-Method Assessment of Sleep Deprivation and Performance in Surgery

BACKGROUND

Minimum rest is mandated in high stake industries such as aviation. The current system of healthcare provision permits on-call surgeons to work in sleep deprived states when performing procedures. Fatigue has been demonstrated to negatively affect performance. This study aimed to explore measurements of sleep deprivation and their impact on simulated performance.

METHODS

This was a single site study conducted between September 2019 and February 2020. Surgical trainee and consultants were conveniently sampled from a single site. All testing was done between 7 AM and 9 AM. Participants completed electroencephalogram testing using a modified Multiple Sleep Latency Test testing for objective sleep measurement, the Pittsburgh Sleep Quality Index, Chalder Fatigue Scale and Epworth Sleepiness Scale for subjective sleep measurement. The Psychomotor Vigilance Task and the SIMENDO simulated tasks were used for standardized performance assessment.

RESULTS

Surgeons entered sleep in 6 min, on average pre-call. This significantly decreased to an average of 164 s post-call (P = 0.016). Pittsburgh Sleep Quality Index scoring was 5, indicating poor baseline sleep quality. There was higher self-reported fatigue and sleepiness in post-call states. Performance decrements were noted in cognitive performance reaction time and aspects of technical instrument proficiency.

CONCLUSIONS

Surgeons are objectively sleep deprived pre-call according to internationally recognized guidelines. This sleep deprivation increases significantly in post-call states. Tasks with higher cognitive demands showed greater levels of diminished performance compared to those with lower cognitive demands. Current models of provision of surgical on-call are not conducive to optimizing sleep in surgeons. Prioritization of workload in post-call states, focusing on preserving individuals cognitive resources and utilizing lower cognitively demanding aspects of work is likely to have positive impacts on performance outcomes.

Effects of exogenous factors on spatial accuracy in neurosurgery

The study aimed to assess the effect of exogenous factors such as surgeon posture, surgical instrument length, fatigue after a night shift, exercise and caffeine consumption on the spatial accuracy of neurosurgical manipulations. For the evaluation and simulation of neurosurgical manipulations, a testing device developed by the authors was used. The experimental results were compared using nonparametric analysis (Wilcoxon test) and multivariate analysis, which was performed using mixed models. The results were considered statistically significant at p < 0.05. The study included 11 first-year neurosurgery residents who met the inclusion criteria. Hand support in the sitting position (Wilcoxon test p value = 0.0033), caffeine consumption (p = 0.0058) and the length of the microsurgical instrument (p = 0.0032) had statistically significant influences on the spatial accuracy of surgical manipulations (univariate analysis). The spatial accuracy did not significantly depend on the type of standing position (Wilcoxon test p value = 0.2860), whether the surgeon was standing/sitting (p = 0.1029), fatigue following a night shift (p = 0.3281), or physical exertion prior to surgery (p = 0.2845). When conducting the multivariate analysis, the spatial accuracy significantly depended on the test subject (p < 0.0001), the use of support during the test (p = 0.0001), and the length of the microsurgical instrument (p = 0.0397). To increase the spatial accuracy of microsurgical manipulations, hand support and shorter tools should be used. Caffeine consumption in high doses should also be avoided prior to surgery.

Sleep deprivation among surgical residents: does it affect performance while practising a laparoscopic intestinal anastomosis?

INTRODUCTION

To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis.

METHODS

A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the fatigue group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the rest group (R), being those who slept at home for more than 7 hours. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches.

RESULTS

402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33,5% anastomoses, as opposed to 19,4% in the rest group (p < 0.01). El rest group performed the anastomosis in 56,75 min and the fatigue group in 61,49 min (p = 0.006). There were no significant differences in the others parameters.

CONCLUSIONS

Fatigue increases the risk of leakage and the time to do the exercise.

Ergonomic assessment of a new hand tool design for laparoscopic surgery based on surgeons' muscular activity

Laparoscopic surgery techniques are customarily used in non-invasive procedures. That said traditional surgical instruments and devices used by surgeons suffer from certain ergonomic deficiencies that may lead to physical complaints in upper limbs and back and general discomfort that may, in turn, affect the surgeon's skills during surgery. A novel design of the laparoscopic gripper handle is presented and compared with one of the most used instruments in this field in an attempt to overcome this problem. The assessment of the ergonomic feature of the novel design was performed by using time-frequency analysis of the surface electromyography (sEMG) signal during dynamic activities. Singular Spectrum Analysis (SSA) was used to decompose the sEMG signal and extract the median frequency of each muscle to assess muscle fatigue. The results reveal that using the proposed ergonomic grip reduces the mean values of the muscle activity during each of the proposed tasks. The novel design also improves the ease of use in laparoscopic surgery as it minimises high-pressure contact areas, reduces large amplitude movements and promotes a neutral position of the hand, wrist and forearm. Furthermore, the SSA method for time-frequency analysis provides a powerful tool to analyse a prescribed activity in ergonomic terms. The proposed methodology to assess muscle activity during surgery activities may be useful in the selection of surgical instruments when programming extended procedures, as it provides an additional selection criterion based on the surgeon's biomechanics and the proposed activity.

Virtual vitreoretinal surgery: effect of distracting factors on surgical performance in medical students

PURPOSE

We aimed to investigate the effect of four distracting factors on surgical performance in virtual vitreoretinal surgery.

METHODS

Nineteen novice surgeons completed a validated training programme on the Eyesi surgical simulator (VRmagic GmbH, Manheim, Germany; software version 2.9.2) until a calculated target score was reached. The training programme consisted of four modules: navigation level 2 (Nav2), bimanual training level 3 (BimT3), posterior hyaloid level 3 (PostH3) and internal limiting membrane peeling level 3 (ILMP3). When properly trained, the participants completed the training programme once without distraction to generate reference scores and times. Next, they conducted the training programme under the influence of each of the following: auditory distraction, 12 hr of fasting, interrupted sleep and 24 hr of sleep deprivation. Wilcoxon signed-rank test was used to compare the distraction-induced results to the participants' reference scores and times.

RESULTS

As compared to reference score (328), a lower performance was found for all four distractions: auditory distraction (289, p = 0.0012), fasting (302, p = 0.02), sleep interruption (304, p = 0.02) and sleep deprivation (300, p = 0.0006). In particular, PostH3 performance was influenced by all four interventions. (86 versus 50, p = 0,0012, 65, p = 0.05, 72, p = 0.05, 54, p = 0.0007 respectively).

CONCLUSIONS

Virtual vitreoretinal surgery is an important tool for practicing complex surgical skills without compromising patient safety. In this study, deleterious effects on surgical performance were induced by four independent distracting factors. This knowledge is useful to optimize surgeons' work conditions and ensuring the best possible treatment of patients.

A systematic review of sleep deprivation and technical skill in surgery

BACKGROUND

It is uncertain if sleep deprivation impacts sleepy surgeons' technical skills. Lapses in surgical performance could increase morbidity and mortality. This review concludes if sleep deprivation impacts on technical skill performance in simulated environments.

OBJECTIVE

Primary: 1. To identify if sleep deprivation has an impact on technical skill proficiency in surgeons. Secondary: a. To identify if the level of surgical experience, quality of sleep, or quantity of sleep influences technical skill proficiency in sleep deprived surgeons.

METHODS

The review was conducted according to PRISMA guidelines utilising the databases Journals Ovid. Validation followed with two independent reviewers utilising an adapted version of BEME.

RESULTS

Thirty-three heterogeneous studies were included. Sleep deprivation likely negatively impacts technical performance between 11.9 and 32% decrement in performance. No strong evidence exists with regards to influence of experience, sleep type, or sleep length on technical proficiency.

CONCLUSION

Sleepy surgeons' technical skills are, on balance, between 11.9 and 32% negatively impacted in a standardised simulated environment. This is likely to have clinical implications for patient safety.

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty

Importance

Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety.

Objective

To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty.

Design, Setting, and Participants

This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018.

Main Outcomes and Measures

Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS).

Results

Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70).

Conclusions and Relevance

The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness.

Level of Evidence

NA.

Endogenous and Exogenous Factors Affecting the Surgical Technique (Review)

In this review, we analyzed essential factors affecting precise manual movements in microsurgery described in the medical literature. The search for publications in English and Russian languages was conducted in the PubMed database without limitation by the date of publication. The search was carried out according to the following descriptors: surgical procedures, dexterity, microsurgery, caffeine, alcohol, nicotine, physical exercise, sleep deprivation, posture. Only randomized and cohort studies involving doctors and students with surgical specialties were included in the analysis. We did not include papers in which only psychological (non-motor) aspects were studied.

Due to the limited number of publications meeting the inclusion criteria and conflicting results in some of them, the presented review does not allow us to formulate unambiguous conclusions and recommendations. Further studies (deep and fundamental) of endogenous and exogenous factors affecting the microsurgical technique are needed.

Impact of Sleep Deprivation on Surgical Laparoscopic Performance in Novices: A Computer-based Crossover Study

OBJECTIVE

The 24-hour work shifts are newly permitted to first-year surgical residents in the United States. Whether surgery novices' motor activity is affected by sleep deprivation is controversial.

MATERIALS AND METHODS

This study assesses sleep deprivation effects in computer-simulated laparoscopy in 20 surgical novices following 24 hours of sleep deprivation and after resting using a virtual-reality trainer. Participants were randomly assigned to perform simulator tests either well rested or sleep deprived first.

RESULTS

Of 3 different tasks performed, no significant differences in total time to complete the procedure and average speed of instruments were found. Instrument path length was longer following sleep deprivation (P=0.0435) in 1 of 3 tasks. Error rates (ie, noncauterized bleedings, perforations, etc.), as well as precision, and accuracy rates showed no difference. None of the assessed participants' characteristics affected simulator performance.

CONCLUSIONS

Twenty-four hours of sleep deprivation does not affect laparoscopic performance of surgical novices as assessed by computer-simulation.

Does sleep deprivation alter virtual reality-based robotic surgical skills?

Introduction

Robotic surgery is widely used in many surgical specialities, and there has been no study to assess the impact of sleep deprivation on the complex environment of robotic surgery.

Aim

To compare specific metrics of selected robotic simulator exercises on sleep-deprived and non-sleep-deprived surgical residents.

Material and methods

We enrolled 20 volunteers, residents in surgery, evaluated before and after an 18-hour overnight shift, regarding their results on virtual robotic surgery simulator – the sleep deprivation (SD) group. As a control group, the same subjects were evaluated 5–7 days after the post-shift evaluation, without having a shift overnight and at least 7 h of sleep the previous night – the non-sleep-deprivation (nSD) group.

Results

A statistically significant difference between the pre-shift and post-shift overall results for all exercises in the SD group and no statistical differences for the nSD group were observed. As the difficulty of the exercises increased, statistical differences were observed on specific metrics for all exercises between the pre-shift and post-shift as well as between the post-shift and the morning after a normal sleep period overnight. In a subgroup analysis, the overall results revealed a stronger statistical difference between pre-shift and post-shift for residents with more intense sleep deprivation (< 3 h of sleep vs. > 3 h of sleep).

Conclusions

Sleep deprivation leads to impairment of surgical skills assessed by robotic virtual simulator. The more complex and skill demanding the exercise, the higher the difference between sleep deprived and non-deprived residents.

Is postponed laparoscopic appendectomy justified for patients with acute appendicitis?

INTRODUCTION

Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial.

METHODS

We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups.

RESULTS

The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher).

CONCLUSIONS

For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery.

Anesthesiology Resident Night Float Duty Alters Sleep Patterns

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Residency programs utilize night float systems to adhere to duty hour restrictions; however, the influence of night float on resident sleep has not been described. The study aim was to determine the influence of night float on resident sleep patterns and quality of sleep. We hypothesized that total sleep time decreases during night float, increases as residents acclimate to night shift work, and returns to baseline during recovery.

Methods

This was a single-center observational study of 30 anesthesia residents scheduled to complete six consecutive night float shifts. Electroencephalography sleep patterns were recorded during baseline (three nights), night float (six nights), and recovery (three nights) using the ZMachine Insight monitor (General Sleep Corporation, USA). Total sleep time; light, deep, and rapid eye movement sleep; sleep efficiency; latency to persistent sleep; and wake after sleep onset were observed.

Results

Mean total sleep time ± SD was 5.9 ± 1.9 h (3.0 ± 1.2.1 h light; 1.4 ± 0.6 h deep; 1.6 ± 0.7 h rapid eye movement) at baseline. During night float, mean total sleep time was 4.5 ± 1.8 h (1.4-h decrease, 95% CI: 0.9 to 1.9, Cohen’s d = –1.1, P &lt; 0.001) with decreases in light (2.2 ± 1.1 h, 0.7-h decrease, 95% CI: 0.4 to 1.1, d = –1.0, P &lt; 0.001), deep (1.1 ± 0.7 h, 0.3-h decrease, 95% CI: 0.1 to 0.4, d = –0.5, P = 0.005), and rapid eye movement sleep (1.2 ± 0.6 h, 0.4-h decrease, 95% CI: 0.3 to 0.6, d = –0.9, P &lt; 0.001). Mean total sleep time during recovery was 5.4 ± 2.2 h, which did not differ significantly from baseline; however, deep (1.0 ± 0.6 h, 0.4-h decrease, 95% CI: 0.2 to 0.6, d = –0.6, P = 0.001 *, P = 0.001) and rapid eye movement sleep (1.2 ± 0.8 h, 0.4-h decrease, 95% CI: 0.2 to 0.6, d = –0.9, P &lt; 0.001 P &lt; 0.001) were significantly decreased.

Conclusions

Electroencephalography monitoring demonstrates that sleep quantity is decreased during six consecutive night float shifts. A 3-day period of recovery is insufficient for restorative sleep (rapid eye movement and deep sleep) levels to return to baseline.

Effects of Sleep Deprivation on Surgeons Dexterity

Sleep deprivation is an ordinary aspect in the global society and its prevalence is increasing. Chronic and acute sleep deprivation have been linked to diabetes and heart diseases as well as depression and enhanced impulsive behaviors. Surgeons are often exposed to long hour on call and few hours of sleep in the previous days. Nevertheless, few studies have focused their attention on the effects of sleep deprivation on surgeons and more specifically on the effects of sleep deprivation on surgical dexterity, often relying on virtual surgical simulators. A better understanding of the consequences of sleep loss on the key surgical skill of dexterity can shed light on the possible risks associated to a sleepy surgeon. In this paper, the authors aim to provide a comprehensive review of the relationship between sleep deprivation and surgical dexterity.

A review of current approaches for evaluating impaired performance in around-the-clock medical professionals

The need for data to study the relationship between fatigued healthcare professionals and performance outcomes is evident, however, it is unclear which methodology is most appropriate to provide these insights. To address this issue, we performed a systematic review of relevant articles by searching the MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL databases. The literature search identified 2960 unique references, of which 82 were identified eligible. The impact on performance was studied on clinical outcomes, medical simulation, neurocognitive performance, sleep quantification and subjective assessment. In general results on performance are conflicting; impairment, no effect, and improvement were found. This review outlines the various methods currently available for assessing fatigue-impaired performance. The contrasting outcomes can be attributed to three main factors: differences in the operationalisation of fatigue, incomplete control data, and the wide variety in the methods used. We recommend the implementation of a clinically applicable tool that can provide uniform data. Until these data become available, caution should be used when developing regulations that can have implications for physicians, education, manpower planning, and ‒ ultimately ‒ patient care.

Ergonomic Assessment of the Mental Workload Confronted by Surgeons during Laparoscopic Surgery

Although the mental workload confronted by laparoscopic surgeons is rather high, there is presently no reliable, established method for evaluating this workload. In the present study, four evaluation indices of eye movement metrics were applied to evaluate surgeons’ mental workload. Correlations between these indices and National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores were also explored. Sixteen participants were recruited to complete four laparoscopic procedures. Eye movement was recorded during the tasks, and NASA-TLX scales were also introduced for subjective evaluation. The data were analyzed using R 3.3.2. Significant differences in the mental workload of each task were observed. Statistically significant correlations between mean pupil diameter change and NASA-TLX scores were also observed. The correlation coefficients were 0.763, 0.675, 0.405, and 0.547, and the P values correspondingly were 0.001, 0.004, 0.12, and 0.028, respectively. The results clarify that the mental workload of laparoscopic surgeons is dependent on the specific demands of the operation. Appropriate objective physiological indices can be used to identify the mental workload state of the surgeon.

Effects of Fatigue Based on Electroencephalography Signal during Laparoscopic Surgical Simulation

Background

Following recent advances in technology, there is a growing interest in studying fatigue based on electrophysiological signals as a means of monitoring brain activity. While some existing works relate fatigue to performance, others consider the two as independent entities. Therefore, we must explore this intricate issue, particularly in laparoscopic training, for the sake of patient safety.

Objective

This paper explores and evaluates effects of fatigue on efficiency and accuracy based on laparoscopic surgical training using Electroencephalography (EEG) signal.

Materials and Methods

20 college students performed peg transfer task on laparoscopic simulator, with real-time recording of EEG signals for each subject. To monitor degree of fatigue, a real-time fatigue monitoring system based on fatigue analysis algorithm was designed through the use of EEG in alpha (α) and theta (θ) rhythms. We designed data acquisition and fatigue analysis modules based on MATLAB platform. BrainLink was used to record EEG signals and send them to personal computer wirelessly via Bluetooth. While artifacts from the captured EEG signals were removed using Blind Source Separation (BSS), α and θ rhythms were extracted using wavelet analysis. Fatigue was evaluated based on Regression Model and Mahalanobis Distance (D_C), and its threshold was determined from the experimental results using Receiver Operating Characteristic (ROC) curve analysis.

Results

Completion time and number of errors behaved like a decreasing function during the first few trials while increasing afterwards with the increasing of perceived fatigue level. The results indicate that learning curve of the subjects is increasing until 13th trials when they have attained maximum learning benefits and decreases afterwards due to fatigue.

Conclusion

Regression analysis shows that there are significant learning and fatigue effects when peg transfer task in the training is repeated in a series of trials. However, for the training to be effective and efficient, there should be monitoring during the training to observe where in the learning curve a trainee gains maximum learning benefits. Furthermore, fatigue is a significant indicator of efficiency and accuracy in terms of completion time and errors, respectively.

Nighttime Trauma Fellow Care Is Associated with Improved Outcomes after Injury

Time of admission and surgeon experience may explain variations in trauma outcomes. We hypothesized that earlier admission time by a more experienced trauma surgeon leads to improved outcomes after injury. We conducted a retrospective cohort study using trauma registry and performance improvement data at our Level 1 trauma center. Consecutive patients presenting at night from 2013 to 2014 were dichotomized into early (6:00 PM–12:00 AM) and late (12:01 AM–7:00 AM) cohorts. Second year trauma fellows acting as attendings and staff trauma surgeons were categorized as less and more experienced, respectively. The primary study outcome was any complication tracked by our state registry, missed injury, delay in diagnosis, or death. The influence of admission time and trauma surgeon experience on this endpoint was examined using multivariable logistic regression. A total of 2078 patients presented either during early (n = 1189) or late (n = 889) night. The cohorts were not different with respect to Deyo–Charlson index, systolic blood pressure, Glasgow Coma Scale, Injury Severity Core, admitting trauma surgeon age, experience, or unadjusted primary study outcome (early 14 vs late 16%; P = 0.206). Trauma surgeon experience was independently predictive of outcomes. Trauma patients admitted at night by fellows were 29 per cent less likely to sustain complications or death than those admitted by staff (adjusted odds ratio 0.71; 95% confidence interval: 0.54–0.92, P = 0.010). This protective effect of fellow care was found only in patients admitted after midnight ( P = 0.03). In conclusion, nighttime initial trauma care by fellows was associated with improved outcomes. Possible explanations include more oversight of nighttime fellow care, variations in daytime responsibilities between fellows and staff, and differential effects of sleep loss by age.

Systematic Review of Factors Influencing Surgical Performance: Practical Recommendations for Microsurgical Procedures in Neurosurgery

BACKGROUND

Microneurosurgical techniques involve complex manual skills and hand-eye coordination that require substantial training. Many factors affect microneurosurgical skills. The goal of this study was to use a systematic evidence-based approach to analyze the quality of evidence for intrinsic and extrinsic factors that influence microneurosurgical performance and to make weighted practical recommendations.

METHODS

A literature search of factors that may affect microsurgical performance was conducted using PubMed and Embase. The criteria for inclusion were established in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) statement.

RESULTS

Forty-eight studies were included in the analysis. Most of the studies used surgeons as participants. Most used endoscopic surgery simulators to assess skills, and only 12 studies focused on microsurgery. This review provides 18 practical recommendations based on a systematic literature analysis of the following 8 domains: 1) listening to music before and during microsurgery, 2) caffeine consumption, 3) β-blocker use, 4) physical exercise, 5) sleep deprivation, 6) alcohol consumption before performing surgery, 7) duration of the operation, and 8) the ergonomic position of the surgeon.

CONCLUSIONS

Despite the clear value of determining the effects of various factors on surgical performance, the available body of literature is limited, and it is not possible to determine standards for each surgical field. These recommendations may be used by neurosurgical trainees and practicing neurosurgeons to improve microsurgical performance and acquisition of microsurgical skills. Randomized studies assessing the factors that influence microsurgical performance are required.

Comparison of experience curves between two 3-dimensional intraoral scanners

STATEMENT OF PROBLEM

Conventional impression-making methods are being replaced by intraoral digital scanning. How long dental professionals take to master the new technologies is unknown.

PURPOSE

The purpose of this human subject study was to compare the experience curves of 2 intraoral scanners among dental hygienists and determine whether repeated scanning experience could change the scan time (ST).

MATERIAL AND METHODS

A total of 29 dental hygienists with more than 3 years of working experience were recruited (group 1: 3-5 years; group 2: >6 years of clinical experience) to learn the iTero and Trios systems. All learners scanned the oral cavities of 4 human participants (participants A, B, C, and D) 10 times (T1-T10) throughout the learning sessions and the experimental dentoform model twice at the beginning and end of the 10 sessions. ST was measured, and changes in ST were compared between the 2 devices.

RESULTS

The average ST for 10 sessions was greater with iTero than with Trios, but the decrease in the measured ST was greater for iTero than for Trios. Baseline and postexperience STs with iTero showed statistically significant differences, with a decrease in time related to the clinical experience levels of the dental hygienists (group 1: T2 and T4, P<.01; group 2: T2 and T5, P<.01). The experience curve with iTero was not influenced by the human participant's intraoral characteristics, and greater ST was shown for participants B and C than for participants A and D with Trios.

CONCLUSIONS

Although the learning rate of iTero was rapid, the average ST for iTero was longer than Trios, and clinical experience levels influenced the operator's ability to manipulate the device. In contrast, the learning rate of Trios was slow, and measured ST was shorter than iTero, and was not influenced by clinical experience.