Deciphering the inflection points to achieve proficiency for each procedure step during training in laparoscopic appendicectomy

Internal and external factors affecting the performance score of surgical trainees doing laparoscopic appendectomy: a prospective, observational cohort study in a structured training programme

BACKGROUND

Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees.

METHODS

A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery.

RESULTS

142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0-75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8-176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0-0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1-0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75-100) min compared to 59 (25-120) min for the non-difficult (p < 0.001).

CONCLUSION

Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation.

Clinical Characteristics, Antimicrobial Resistance, and Outcomes of Patients with Invasive Pneumococcal Disease in Ningxia Hui Autonomous Region, China, 2013-2021

Objectives

This study aimed to analyze the clinical features, antibiotic susceptibility profiles, and outcomes of patients with invasive pneumococcal disease (IPD) at a hospital in Ningxia Hui Autonomous Region, to provide the basis for improving the clinical treatment effect.

Methods

Patients with IPD were retrospectively collected from 2013 to 2021. Clinical manifestations, laboratory tests, antimicrobial susceptibility, antibiotic treatment, and outcomes of the disease were analyzed.

Results

In this study, we identified 127 IPD cases, of whom 49 (38.6%) had meningitis and 78 (61.4%) had bacteremia. The median ages of pediatric cases and adult cases were 2 years (IQR: 0-5) and 52.5 years (IQR: 35-62), respectively. There were 27 and 45 males in the pediatric and adult groups, and no significant gender difference in the different age groups (p = 0.584) was found. Of 75 cases with underlying diseases, pneumonia (11%), malignancy (11%), hypertension (9.4%), and hepatic cirrhosis (7.9%) were the most common. The incidence of underlying diseases was even higher in the adult group (67.1%) than in the pediatric group (47.1%) (p = 0.028). The frequency of fever, cough, and seizures was significantly higher in the pediatric group than in the adult group, with p-values of 0.004, 0.004, and 0.001, respectively. The percentage of neutrophils in the blood was significantly higher in the adult cases than in the pediatric cases (p  <  0.001). Furthermore, there was a significantly higher WBC count (p  <  0.001), percentage of neutrophils (p = 0.012), and protein level (p = 0.019) in the CSF samples in the adult patients compared to pediatric patients. The susceptibility rates of S. pneumoniae isolates to vancomycin, linezolid, and levofloxacin were 100%. The susceptibility rates of penicillin were 98.7% and 34.1% in bacteremia and meningitis patients, respectively. Most isolates were resistant to erythromycin, clindamycin, tetracycline, and azithromycin. The most common antibiotic treatment was β-lactams. Seven (5.5%) patients died during hospitalization, and 38 (29.9%) patients' health deteriorated.

Conclusion

These results may provide a reference basis for the diagnosis and empiric treatment of IPD in the region.

OUP accepted manuscript

BACKGROUND

Surgical training is aimed towards entrusted professional activity to obtain operative independence. Laparoscopic appendicectomy is performed early in training but except for simulators, real-life evaluation towards proficiency is scarce. The aim of this study was to model how each consecutive step may impact on the overall proficiency score for surgical trainees performing laparoscopic appendicectomy.

METHODS

This was an observational cohort study of laparoscopic appendicectomy performed by junior trainees (PGY1-4) under supervision and evaluated for each of eight steps. Each step was scored on a validated six-point performance scale and classified as 'fail', 'pass', or 'proficient'. Modelling was conducted with a multivariable regression model and artificial neural network model with a multilayer perceptron for the relationship between steps and overall performance.

RESULTS

Of 157 procedures, 97 (61.8 per cent) procedures were evaluated as 'proficient', 46 (29.3 per cent) were 'pass', and 14 (8.9 per cent) were 'fail'. In regression analyses, handling the mesoappendix was significantly associated with procedure proficiency, as were division of appendix, access to abdomen, and ability to handle the small bowel. The widest variation in operative flow was shown for steps involving mesoappendix and division of appendix, conceptualized in 'ebb-and-flow' and 'string-of-pearls' models. Sensitivity analyses for experience using 20 or fewer, 30 or fewer, or more than 30 procedures as cut-offs reproduced comparable results.

CONCLUSIONS

Consistent stumbling blocks for junior trainees performing laparoscopic appendectomies can be conceptualized through novel models that identify steps deemed to be the most difficult to trainees with variable experience.