Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy

A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy

BACKGROUND AND OBJECTIVE

The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP.

METHODS

A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively.

KEY FINDINGS AND LIMITATIONS

Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements.

PATIENT SUMMARY

In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study

BACKGROUND

Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown.

METHODS

Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill.

RESULTS

Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041).

CONCLUSIONS

Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

Bariatric surgery in Mexico: training, practice and surgical trends

Bariatric surgery is extremely safe and effective, but several factors need to be addressed to obtain such results. Patient selection, type of training, accreditation, type of practice, and surgical trends and technique are involved in this process. Local and global standardization are ill-advised, especially in countries with high obesity prevalence, and where the bariatric practice is fast growing.An online survey with 22 questions was sent to bariatric surgeons in Mexico. Only participants with the active practice were included, and the aim was to obtain for the first time insight in bariatric surgery training, characteristics of current practice and surgical trends.Complete responses from 114 surgeons were obtained. Most were male, under 50 years-old, ≤ 10 years of experience, and practice in low-volume hospitals. Less than half had a 12-month formal training. Gastric bypass and sleeve gastrectomy were the most common procedures. Practice trends like leak tests, use of drains, preoperative weight loss, routine endoscopy, and pharmacological tromboprofilaxis are common. In surgical technique, the gastric bypass and sleeve gastrectomy confection was more homogenic when compared to the one-anastomosis gastric bypass.Complete responses from 114 surgeons were obtained. Most were male, under 50 years-old, ≤ 10 years of experience, and practice in low-volume hospitals. Less than half had a 12-month formal training. Gastric bypass and sleeve gastrectomy were the most common procedures. Practice trends like leak tests, use of drains, preoperative weight loss, routine endoscopy, and pharmacological tromboprofilaxis are common. In surgical technique, the gastric bypass and sleeve gastrectomy confection was more homogenic when compared to the one-anastomosis gastric bypass. An important number of bariatric surgeons in Mexico are young, male, and with < 10 years of practice. The most common techniques performed are gastric bypass and sleeve gastrectomy. Several practices and technique trends are similar to global consensus. Fellowship programs and Board Certification in bariatric surgery are major advances in our country, thus standardization and high-quality practice can be achieved.

Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy

Importance

In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes.

Objective

To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy.

Design, Setting, and Participants

In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016.

Exposures

Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing.

Main Outcomes and Measures

The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument).

Results

A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47).

Conclusions and Relevance

Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.

Can a Structured, Video-Based Cadaver Curriculum Demonstrating Proficiency Enhance Resident Operative Autonomy?

INTRODUCTION

Autonomy is of foremost concern in the current era of surgical residency, and it is especially important to trainees when considering their surgical education. Factors impacting trainee independence include the restriction of clinical work hours and the development of advanced minimally invasive techniques such as robotics, which requires separate technical education outside of conventional surgical education. Moreover, when residents are left to learn fundamental exposures via their clinical experience alone, they run the risk of not being exposed to some fundamental skills based on case volume and type. The Department of Surgery at Emory University developed a cadaver-based simulation curriculum to standardize exposure to fundamental operative skills and enhance proficiency outside the operating room, with the larger aim of improving resident autonomy.

METHODS

Residents were assigned to small groups led by a chief resident with an even distribution of postgraduate year (PGY) levels. Each group participated in core surgical exposures and fundamental maneuvers on a cadaver over a 6-hour session. Residents were tested on skills according to their PGY level about 1 month after the course. Testing included recitation of the skill in an oral boards format, highlighting major steps, followed by performance of the skill. All steps were video-recorded with no resident identifiers. These were reviewed by 2 independent, blinded faculty examiners who assigned proficiency grades to each resident video.

RESULTS

Three hundred and thirty-three individual procedure evaluations were done over the 5-year period. Senior residents (PGY3-5) had 86% pass rate while junior residents (PGY1-2) had 70% pass rate. Overall, 21% of residents failed to achieve competence in their assigned skills. Junior residents were less likely to achieve competence compared to senior residents. Faculty graders had improved congruence in grading as the course progressed through the 5 years. The most recent 2 years had >80% congruence in faculty grading compared to less than 50% congruence in the first 2 years. 81% of attendings agreed this course positively influenced the granting of autonomy in the operating room.

CONCLUSIONS

A cadaveric skills course focused on fundamental maneuvers with objective confirmation of achieving competency is a viable adjunct to clinical operative experience. Video-recorded evaluation, of these fundamental skills improved both resident and attending confidence in trainee operative skill.

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

Importance

Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy.

Objective

To determine if technical variables during RPD are associated with postoperative DGE.

Design, Setting, and Participants

A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016.

Exposures

Video review of gastrojejunal anastomosis during RPD.

Main Outcomes and Measures

Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined.

Results

Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04).

Conclusions and Relevance

This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.

Using video review to understand the technical variation of robot-assisted radical prostatectomy in a statewide surgical collaborative

PURPOSE

Video assessment is an emerging tool for understanding surgical technique. Patient outcomes after robot-assisted radical prostatectomy (RARP) may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a surgical collaborative.

METHODS

The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative with the aim of improving prostate cancer care. MUSIC surgeons were invited to submit representative complete videos of nerve-sparing RARP for blinded analysis. We also analyzed peri-operative outcomes from these surgeons in the registry.

RESULTS

Surgical video data from 20 unique surgeons identified many variations in technique and time to complete different steps. Common to all surgeons was a transperitoneal approach and a running urethrovesical anastomosis. Prior to anastomosis, 25% surgeons undertook a posterior reconstruction and 30% employed urethral suspension. 65% surgeons approached the seminal vesicle anteriorly. For control of the dorsal vein complex, suture ligation was used in 60%, and vascular stapler was 15%. The majority (80%) of surgeons employed clips for managing pedicles. In examining patient outcomes for surgeons, peri-operative outcomes were not correlated with surgeon's operative time; however, surgeons with an EBL > 400 ml had significant difference among the five different techniques employed.

CONCLUSIONS

Despite the worldwide popularity of RARP, the operation is still far from standardized. Correlating variation in technique with clinical outcomes may help provide objective data to support best practices with the goal to improve patient outcomes.

Methodology for Developing an Educational and Research Video Library in Minimally Invasive Surgery

OBJECTIVE

Explore the methods used and costs necessary for the creation and maintenance of a surgical video library with an emphasis on its applications in surgical education and scholarship.

DESIGN

A methodology paper highlighting how to develop and utilize a surgical video library for trainee operative preparation, development of research projects, and surgeon credentialing.

SETTING

The study was conducted at the University of Pittsburgh Medical Center, a tertiary care medical center.

PARTICIPANTS

Not applicable.

RESULTS

The video library includes all recorded robotic operations performed by the Division of Surgical Oncology at the University of Pittsburgh from 2010 to 2018. It includes 929 videos of which 110 selected videos are uploaded for trainee review online to prepare for upcoming operations. These procedures are broken into steps to create intraoperative time metrics for trainee integration. Fellows operated from console in 85% of robotic cases and all 30 fellows could obtain robotic privileges based on case logs. To date 102 short scholarly videos have been created: 7 for manuscripts, 13 as video submissions, 27 in book chapters, and 55 for presentations. Three papers have been published using video review to determine clinical outcomes with four more under evaluation. The cost of the program is <$10,000 annually.

CONCLUSIONS

Video libraries can be efficiently created utilizing intraoperative recorders for minimally invasive surgery. Breaking surgeries into distinct steps can aid in deliberate integration and answer clinical questions. Overall video libraries are cost effective tools for trainee education, research, and ultimately surgeon credentialing.