1
|
Vallance A, Tcherveniakov P, Bogdan C, Chaudhuri N, Milton R, Kefaloyannis E. The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy. Ann R Coll Surg Engl 2016; 99:129-133. [PMID: 27502339 DOI: 10.1308/rcsann.2016.0253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Unplanned conversion to thoracotomy remains a major concern in video assisted thoracoscopic surgery (VATS) lobectomy. This study aimed to investigate the development of a VATS lobectomy programme over a five-year period, with a focus on the causes and consequences of unplanned conversions. METHODS A single centre retrospective review was performed of patients who underwent complete anatomical lung resection initiated by VATS between January 2010 and April 2015. RESULTS In total, 1,270 patients underwent a lobectomy in the study period and 684 (53.9%) of these were commenced thoracoscopically. There were 75 cases (10.9%) with unplanned conversion. The proportion of lobectomies started as VATS was significantly higher in the second half of the study period (2010-2012: 277/713 [38.8%], 2013-2015: 407/557 [73.1%], p<0.001). The conversion rate dropped initially from 20.4% (11/54) in 2010 to 9.9% (15/151) in 2013 and then remained consistently under 10% until 2015. Conversions were most commonly secondary to vascular injury (26/75, 34.7%). Patients undergoing unplanned conversion had a longer length of stay than VATS completed patients (9 vs 6 days, p<0.001). There was a higher incidence of respiratory failure (10/75 [14.1%] vs 23/607 [3.8%], p<0.001) and 30-day mortality (7/75 [9.3%] vs 6/607 [1.0%], p=0.003) in patients with unplanned conversion than in those with completed VATS. CONCLUSIONS As our VATS lobectomy programme developed, the unplanned conversion rate dropped initially and then remained constant at approximately 10%. With increasing unit experience, it is both safe and technically possible to complete the majority of lobectomy procedures thoracoscopically.
Collapse
Affiliation(s)
| | | | - C Bogdan
- Leeds Teaching Hospitals NHS Trust , UK
| | | | - R Milton
- Leeds Teaching Hospitals NHS Trust , UK
| | | |
Collapse
|
2
|
Reznick D, Niazov L, Holizna E, Keebler A, Siperstein A. Dedicated teams to improve operative room efficiency. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.pcorm.2016.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
3
|
Giza DE, Tudor S, Purnichescu-Purtan RR, Vasilescu C. Robotic Splenectomy: What is the Real Benefit? World J Surg 2014; 38:3067-73. [DOI: 10.1007/s00268-014-2697-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
4
|
Fanous M, Carlin A. Surgical resident participation in laparoscopic Roux-en-Y bypass: Is it safe? Surgery 2012; 152:21-5. [PMID: 22503322 DOI: 10.1016/j.surg.2012.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The majority of bariatric surgeons use dedicated surgical assistants when performing laparoscopic Roux-en-Y gastric bypass (LGBP) because of the technical difficulty and steep learning curve involved in the operation. At our institution, either a senior surgical resident (SSR) or a physician assistant (PA) participates in LGBP cases. The PA's role is confined to assisting, whereas the SSR progressively acts as the operating surgeon. We were interested in evaluating patient outcomes to determine whether any differences existed between the LGBP operations in which either the PA or the SSR participated. METHODS All patients undergoing LGBP between January 2007 and December 2009 in our prospectively collected bariatric database were reviewed. Demographics, baseline measures, intraoperative parameters, and outcomes were compared. RESULTS A total of 711 patients were identified. The group involving PAs included 343 patients, and the group involving SSRs included 368 patients. Preoperative comorbidities, including diabetes, hypertension, coronary artery disease, asthma, sleep apnea, hyperlipidemia, musculoskeletal disability, and depression, were similar in both groups. Personal histories of venous thromboembolism were higher in the PA group (5.1% vs 2.5%; P = .075). The mean body-mass indexes (BMI) (53 ± 9 vs 51 ± 8 kg/m(2); P = .006) and weights (323 ± 67 vs 306 ± 59 lbs; P < .001) in the PA group were significantly higher than in the SSR group. The proportion of males was higher in the PA group (24% vs 16%; P = .008). The operative time was significantly shorter in the PA group (121 ± 36 vs 164 ± 30 minutes; P < .001). There was no significant difference between the groups in intraoperative complications, length of hospital stay, 30-day complications, or reoperations within 1 year. There were no mortalities in either group. The 1-year percent excess weight loss (64% vs 66%) was similar in the PA and SSR groups, respectively. CONCLUSION SSR participation in LGBP prolongs operative time but does not increase complications, mortality rates, or length of stay. Therefore, SSR participation in LGBP is safe and produces outcomes comparable to those performed with PAs.
Collapse
Affiliation(s)
- Medhat Fanous
- Department of General Surgery, Henry Ford Hospital, Detroit, MI, USA.
| | | |
Collapse
|
5
|
Nursal TZ, Ezer A, Belli S, Parlakgumus A, Caliskan K, Noyan T. Reaching proficiency in laparoscopic splenectomy. World J Gastroenterol 2009; 15:4005-8. [PMID: 19705495 PMCID: PMC2731950 DOI: 10.3748/wjg.15.4005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method.
METHODS: All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n = 33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups.
RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters.
CONCLUSION: Unlike the widely accepted “L” shape, the learning curve for laparoscopic splenectomy is a horizontal lazy “S” with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.
Collapse
|
6
|
Kotsanas D, Al-Souffi MH, Waxman BP, King RWF, Polkinghorne KR, Woolley IJ. ADHERENCE TO GUIDELINES FOR PREVENTION OF POSTSPLENECTOMY SEPSIS. AGE AND SEX ARE RISK FACTORS: A FIVE-YEAR RETROSPECTIVE REVIEW. ANZ J Surg 2006; 76:542-7. [PMID: 16813615 DOI: 10.1111/j.1445-2197.2006.03775.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Vaccination, education and use of long-term antibiotics are recommended in expert guidelines for the prevention of infectious complications after splenectomy. However, studies outside Australia have shown poor adherence to the guidelines. METHOD The aim of this study was to determine overall adherence to the guidelines and to ascertain any independent risk factors for poor compliance with the guidelines. A retrospective review of hospital records between 1999 and 2004 was carried out. RESULTS Indications for splenectomy of the 111 patients in this review included post-trauma (32), haematological (32), cancer surgery (24), iatrogenic (12) and others (11). On multivariable analysis, age was associated with a 28% less likelihood to receive education (odds ratio (OR) 0.72; 95% confidence interval (CI) 0.56-0.92; P = 0.009) and 36% less likelihood to receive long-term antibiotics (OR 0.64; 95% CI 0.52-0.80; P < or = 0.001). Women were four times more likely to receive education (OR 4.03; 95% CI 1.16-14.0; P = 0.028) and patients who had undergone splenectomy in 2004 were 22 times more likely to have received education compared with those in 1999 (OR 22.53; 95% CI 3.12-162.34; P = 0.002). CONCLUSION Education for prevention of sepsis after splenectomy is poorly documented and may be incomplete. Older age and male sex are risk factors in non-adherence to guidelines for prevention of postsplenectomy sepsis. Strategies such as alert cards and information brochures may improve adherence to guidelines particularly in older patients.
Collapse
Affiliation(s)
- Despina Kotsanas
- Department of Infectious Diseases, Monash Medical Centre, Melbourne, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
7
|
Pomp A, Gagner M, Salky B, Caraccio A, Nahouraii R, Reiner M, Herron D. Laparoscopic splenectomy: a selected retrospective review. Surg Laparosc Endosc Percutan Tech 2005; 15:139-43. [PMID: 15956897 DOI: 10.1097/01.sle.0000166990.66980.78] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.
Collapse
Affiliation(s)
- Alfons Pomp
- Department of Surgery, Weill Medical College of Cornell University, New York, NY 10021, USA.
| | | | | | | | | | | | | |
Collapse
|
8
|
Abstract
PURPOSE The purpose of this study was to answer the question: How many cases are required for a surgeon to become proficient in performing arthroscopic rotator cuff repair? We hypothesize that as surgical experienced is gained, learning can be quantitatively shown by a significant decrease in operative time. TYPE OF STUDY Prospective case series. METHODS Rotator cuff repair time (RCRT) in minutes (as well as other time components comprising total surgical time) was recorded for 100 consecutive patients having arthroscopic rotator cuff repair performed by a single surgeon beginning with his first case in private practice. Mean RCRTs for consecutive blocks of 10 cases were compared. Learning is graphically represented by plotting the RCRT by case number and generating a logarithmic trend curve. A best-fit linear equation (y = mx + b) allows comparison of the initial 10 cases with the subsequent 90 cases, where m , the slope, represents the rate of decrease in RCRT (learning). RESULTS Mean RCRT decreased significantly (P < .05) from the first block of 10 cases to the second block of 10 cases. There were no significant changes in mean RCRT when comparing other consecutive blocks of 10 cases. The slope of the line fitting the first block of 10 cases is -8.75; the slope (m) of the line fitting the subsequent 90 cases is -0.23. There is no significant difference in mean RCRT when cases are stratified by tear size. CONCLUSIONS Graphic representation of RCRT by case number generates a learning curve whereby learning is quantitatively shown as a significant decrease in operative time as surgical experience is gained. CLINICAL RELEVANCE Qualification of the learning curve for arthroscopic rotator cuff repair provides a guide for orthopaedic surgeons contemplating the expected time line for acquiring proficiency in this technique.
Collapse
Affiliation(s)
- Dan Guttmann
- Taos Orthopaedic Institute Research Foundation Taos, New Mexico 87571, USA
| | | | | | | |
Collapse
|
9
|
Glasgow RE, Adamson KA, Mulvihill SJ. The benefits of a dedicated minimally invasive surgery program to academic general surgery practice. J Gastrointest Surg 2004; 8:869-73; discussion 873-5. [PMID: 15531241 DOI: 10.1016/j.gassur.2004.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In 2001, a dedicated minimally invasive surgery (MIS) program was established at a large university hospital. Changes included improvement and standardization of equipment and instruments, patient care protocols, standardized orders, and staff education. The aim of this study was to evaluate the impact of this program on an academic surgery practice. From January 1999 through October 2003, hospital and departmental databases were reviewed for all records pertaining to general surgery cases. Data trends were analyzed by regression analysis and are expressed as mean +/- SEM. In 1999, 15.0 +/- 0.1% of all general surgery cases were MIS cases compared with 30.2 +/- 0.1% in 2003 (P < 0.0001). During this period, the number of patients requiring conversion from a laparoscopic to an open approach decreased from 14.4% to 4.0% (P = 0.0007). In 1999, 30% of appendectomies were laparoscopic, compared with 92% in 2003 (P < 0.0001). This increase in the rate of laparoscopic appendectomy resulted in a decrease in average length of hospital stay for all patients with acute appendicitis, from 5.5 +/- 1.0 days in 1999 to 2.7 +/- 0.2 days in 2003 (P < 0.0001), and a decrease in total hospital cost per case, from 6569 +/- 400 US dollars in 1999 to 4819 +/- 175 US dollars in 2002 (P < 0.001). Total operating room time per case for cholecystectomy decreased from 131 +/- 3.7 to 108 +/- 3.2 minutes (P < 0.0001), and actual surgery time decreased from 95 +/- 4.1 to 74 +/- 4.0 minutes (P = 0.0006). Implementation of a dedicated MIS program resulted in a significant increase in the number of MIS cases and percentage of general surgery cases performed by MIS. This increase in the utilization of MIS resulted in reduced length of stay and cost and has been accompanied by improvements in operating room efficiency. Changes in practice associated with development of an MIS program have had measurable institutional benefits.
Collapse
Affiliation(s)
- Robert E Glasgow
- Department of Surgery, University of Utah, Salt Lake City, UT 84132-2806, USA.
| | | | | |
Collapse
|
10
|
Kojouri K, Vesely SK, Terrell DR, George JN. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood 2004; 104:2623-34. [PMID: 15217831 DOI: 10.1182/blood-2004-03-1168] [Citation(s) in RCA: 428] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractSplenectomy has been a standard treatment for adult patients with idiopathic thrombocytopenic purpura (ITP) for more than 50 years. However, the durability of responses, the ability to predict who will respond, and the frequency of surgical complications with splenectomy all remain uncertain. To better interpret current knowledge we systematically identified and reviewed all 135 case series, 1966 to 2004, that described 15 or more consecutive patients who had splenectomy for ITP and that had data for 1 of these 3 outcomes. Complete response was defined as a normal platelet count following splenectomy and for the duration of follow-up with no additional treatment. Forty-seven case series reported complete response in 1731 (66%) of 2623 adult patients with follow-up for 1 to 153 months; complete response rates did not correlate with duration of follow-up (r = -0.103, P = .49). None of 12 preoperative characteristics that have been reported consistently predicted response to splenectomy. Mortality was 1.0% (48 of 4955 patients) with laparotomy and 0.2% (3 of 1301 patients) with laparoscopy. Complication rates were 12.9% (318 of 2465) with laparotomy and 9.6% (88 of 921 patients) with laparoscopic splenectomy. Although the risk of surgery is an important consideration, splenectomy provides a high frequency of durable responses for adult patients with ITP. (Blood. 2004; 104:2623-2634)
Collapse
Affiliation(s)
- Kiarash Kojouri
- Hematology-Oncology Section, Department of Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | | | | | | |
Collapse
|
11
|
Cordera F, Long KH, Nagorney DM, McMurtry EK, Schleck C, Ilstrup D, Donohue JH. Open versus laparoscopic splenectomy for idiopathic thrombocytopenic purpura: clinical and economic analysis. Surgery 2003; 134:45-52. [PMID: 12874582 DOI: 10.1067/msy.2003.204] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since 1991, laparoscopic splenectomy (LS) has gained acceptance in the treatment of hematologic disorders, including idiopathic thrombocytopenic purpura (ITP). Several studies suggest that LS provides benefits over open splenectomy (OS). However, study design flaws hinder formal technology assessment. METHODS We retrospectively reviewed medical and administrative records of patients who underwent splenectomy for ITP between January 1995 and December 2000 to compare clinical and economic outcomes associated with LS and OS. RESULTS Eighty-six patients were identified; 42 underwent an attempted LS and 44 had OS. Preoperative patient characteristics were similar between groups. Mean operative and anesthesia times for LS and OS were 167 and 201 minutes and 119 and 151 minutes, respectively (P <.001). Overall transfusion and postoperative complication rates were similar between groups. On average, LS patients required 1.2 fewer days of parenteral analgesia and were able to tolerate a general diet 1.7 days earlier. Mean postoperative stay was 2 days lower for LS patients and mean total direct costs did not differ by surgical method (US dollars 8134 vs US dollars 8200). CONCLUSIONS This observational study shows that LS is safe and offers advantages over OS: less postoperative pain, earlier general diet tolerance, and shorter hospital stay. These benefits are obtained at no significant additional cost.
Collapse
Affiliation(s)
- Fernando Cordera
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | | | | | | | |
Collapse
|
12
|
Fielding GA. Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy. ANZ J Surg 2002; 72:459. [PMID: 12123496 DOI: 10.1046/j.1445-2197.2002.02493.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|