A monitoring tool for performance improvement in plastic surgery at the individual level

Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery

Objective: Robotic platforms offer articulating needle drivers but are associated with high costs and lack tactile feedback. The recently developed mechanical Laparoscopic Articulating Needle Driver (LAND) (Flexdex^®) for conventional laparoscopy offers enhanced dexterity without these limitations. The goal of this study was to assess safety and efficiency during the implementation of the LAND, and describe its learning curve, in an expert center for laparoscopic surgery. Methods: All LAND-assisted procedures after clinical implementation for a period of 16 months were included into this study. Primary outcome domains were safety (intra- and postoperative complications within 30 days) and efficiency (operative time, suturing, and knot tying time of staple defects of enteroenterostomy). CUmulative SUM (CUSUM) analysis was utilized to describe the enteroenterostomy suturing time learning curve across consecutive cases by plotting the deviation from the series mean. Results: Forty-five procedures (34 Roux-en-Y gastric bypass [of which 7 including diaphragmatic hernia repair], 2 diaphragmatic hernia repair with Nissen fundoplication, and 2 right-sided hemicolectomy) were included into this study. Median (range) operative time and enteroenterostomy suturing time were 68 (46-177) minutes and 161 (112-241) seconds, respectively, comparable with conventional needle driver standards. One procedure was converted to the conventional needle driver due to device malfunctioning and one patients' postoperative course was complicated by a Clavien-Dindo grade 3a complication (intraluminal bleeding requiring gastroscopy). CUSUM chart displays a progression toward the mean from case 22 onward, indicating a limited learning curve. Conclusion: The LAND can be implemented safely and efficiently at a center of excellence for laparoscopic surgery and is associated with a limited learning curve.

Successful Sleeve Resection as a Marker for Proficiency for Robotic Pulmonary Resection

BACKGROUND

 Robot technology is a revolutionary technique to overcome limitations of minimal invasive surgery. The proficiency level varies from study to study. We considered the first sleeve lobectomy as a benchmark procedure to evaluate the proficiency level.

METHODS

 We retrospectively analyzed 197 patients who underwent robot-assisted thoracoscopic surgery (RATS) for primary lung cancer between December 2011 and May 2018. Patients were divided into two groups based on undergoing surgery earlier period (EP) or later period (LP) than the first sleeve lobectomy by RATS (May 25, 2015). The preoperative, operative, and short- and long-term postoperative outcomes were compared. Seven-year survival was also compared between two periods for T1N0 and T2N0 diseases.

RESULTS

 Preoperative features were similar. The mean operative time was 166.8 ± 55.1 and 142.4 ± 43.9 minutes in EP and LP, respectively (p = 0.005). The mean number of dissected lymph nodes in LP was also significantly higher than that in EP (24.4 ± 9.4 vs. 20.8 ± 10.4, p = 0.035). The complication rate was significantly lower in LP (29/86 vs. 25/111, p = 0.048). The extended resection (ER) rate was significantly higher in LP (p = 0.023). The 7-year survival was comparable in EP and LP in both patients with T1N0 and T2N0 (p = 0.28 and p = 0.11, respectively).

CONCLUSION

 Perioperative outcomes, such as duration of surgery, number of dissected lymph nodes, complications, and ERs are favorable in patients who underwent surgeries after the first sleeve resection. The first sleeve lobectomy may be considered as the benchmark procedure for the proficiency level in RATS.

Influence of Daily Variations in Individual Surgeon's Operative Time on Patient Outcomes

BACKGROUND

Evidence is lacking regarding the potential association between daily variation in individual surgeon's operative time, procedure after procedure, and risk of patient complication. We assumed that surgeon deviation from the expected procedure duration may be harmful for patient.

METHOD

All patients who underwent a thyroidectomy undertaken in five hospitals during a 1-year period were included prospectively. For each thyroidectomy, we estimated the expected operative time from a multilevel linear regression considering the attending surgeon who performed the operation, the patient preoperative risk, and the procedure complexity. Three groups of thyroidectomies were identified according to whether the observed duration is: slower than expected, as expected, or faster than expected. Rates of permanent recurrent laryngeal nerve palsy and hypoparathyroidism at 6 months were then compared between these groups.

RESULTS

A total of 3102 patients who underwent a thyroidectomy undertaken by 22 surgeons were considered. Risk of laryngeal nerve palsy was higher in the "slow" group than in the "normal" group (OR = 4.63, 95% confidence interval 2.21-9.70), as was that of hypoparathyroidism (OR = 2.43, 95% confidence interval 1.21-4.88). There was no significant difference between "fast" and "normal" groups for either complication. Deviation from expected procedure duration was more frequent at the end than at the beginning of the daily operation schedule (29.4% vs. 18.3%, respectively, P < .001).

CONCLUSION

Patients had a greater risk of complication when the surgeon performed thyroidectomy slower than expected. Surgeons avoiding excessive deviations from their expected procedures durations reflect safer practice.

The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis

OBJECTIVES

The independent impact of individual surgical experience and team familiarity on surgical performance has been widely studied; however, the interplay of these factors and their relative, quantified, contributions to performance is poorly understood. We determined the impact of team familiarity and surgeon, and cumulative team experience on operative efficiency in total knee replacement.

DESIGN

Retrospective analysis of all total knee replacements conducted at the host institution in 1996-2009. Multivariate generalised-estimating-equation regression models were used to adjust for patient risk and clustering.

SETTING

Tertiary care academic hospital.

PARTICIPANTS

All patients undergoing TKR at the host institution in 1996-2009.

MAIN OUTCOME MEASURE

Operative efficiency.

RESULTS

A total of 4276 total knee replacements were completed by 1163 different surgical teams. The median experience level was 17.6 years for consultant surgeons and 3.7 years for trainee surgeons. After patient-risk adjustment, consultant surgical experience (p < 0.0001), trainee surgical experience (p < 0.05), cumulative team operative experience (p < 0.0001) and team familiarity (p < 0.0001) were associated with significant reductions in operative time. Surgical experience and team familiarity demonstrated concave and linear relationships with operative time, respectively. For a consultant surgeon, the expected reduction in operative time after 25 years in practice was 51 min, compared to a 21-min reduction over the span of 40 collaborations with the same team members.

CONCLUSIONS

Surgical experience and team familiarity display important and distinct relationships with operative time in total knee replacement. Appreciation of this interplay may serve to guide implementation and allocation of procedure-specific quality improvement strategies in surgery.

Surgical learning curves and operative efficiency: a cross-specialty observational study

OBJECTIVES

To evaluate the learning curves of three high-volume procedures, from distinct surgical specialties.

SETTING

Tertiary care academic hospital.

PARTICIPANTS

A prospectively collected database comprising all medical records of patients undergoing isolated coronary artery bypass grafting (CABG), total knee replacement (TKR) and bilateral reduction mammoplasty (BRM) at the Brigham and Women's Hospital, USA, 1996-2010. Multivariate generalised estimating equation (GEE) regression models were used to adjust for patient risk and clustering of procedures by surgeon.

PRIMARY OUTCOME MEASURE

Operative efficiency.

RESULTS

A total of 1052 BRMs, 3254 CABGs and 3325 TKRs performed by 30 surgeons were analysed. Median number of procedures per surgeon was 61 (range 11-502), 290 (52-973) and 99 (10-1871) for BRM, CABG and TKR, respectively. Mean operative times were 134.4 (SD 34.5), 180.9 (62.3) and 101.9 (30.3) minutes, respectively. For each procedure, attending surgeon experience was associated with significant reductions in operative time (p<0.05). After 15 years of experience, BRM operative time decreased by 69.8 min (38.3%), CABG operative time decreased by 17.5 min (7.8%) and TKR operative time decreased by 94.4 min (48.4%).

CONCLUSIONS

Common trends in surgical learning exist. Dependent on the procedure, experience can serve as a powerful driver of improvement or have clinically insignificant impacts on operative time.

The primary determinants of radiation use during fixation of proximal femur fractures

OBJECTIVES

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma centre.

COHORT

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

MAIN OUTCOME MEASURES

Fluoroscopy time, dose-area-product (DAP).

RESULTS

Longer fluoroscopy time was correlated with higher body mass index (p=0.04), subtrochanteric fracture (p<0.001), attending surgeon (p=0.001), and implant type (p<0.001). Increased DAP was associated with higher body mass index (p<0.001), subtrochanteric fracture (p=0.002), attending surgeon (p=0.003), lateral body position (p<0.001), and implant type (p=0.05).

CONCLUSION

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.