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AlQahtani A, London NR, Castelnuovo P, Locatelli D, Stamm A, Cohen-Gadol AA, Elbosraty H, Casiano R, Morcos J, Pasquini E, Frank G, Mazzatenta D, Barkhoudarian G, Griffiths C, Kelly D, Georgalas C, Janakiram N, Nicolai P, Prevedello DM, Carrau RL. Assessment of Factors Associated With Internal Carotid Injury in Expanded Endoscopic Endonasal Skull Base Surgery. JAMA Otolaryngol Head Neck Surg 2021; 146:364-372. [PMID: 32105301 DOI: 10.1001/jamaoto.2019.4864] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors. Objective To assess the factors associated with ICA injury in an effort to reduce its occurrence. Design, Setting, and Participants This quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury. Main Outcomes and Measures Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data. Results Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations. Conclusions and Relevance This study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.
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Affiliation(s)
- Abdulaziz AlQahtani
- Department of Otorhinolaryngology-Head & Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus.,Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Aldo Stamm
- Centro de Otorrinolaringologia e Fonoaudiologia, Complexo Hospitalar Edmundo Vasconcelos, São Paulo, Brasil
| | - Aaron A Cohen-Gadol
- Indiana University, Department of Neurosurgery and Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Hussam Elbosraty
- Department of Otorhinolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Roy Casiano
- Department of Otolaryngology-Head & Neck Surgery, University of Miami, Miller School of Medicine, Miami, Florida
| | - Jacques Morcos
- Department of Neurosurgery, University of Miami, Miami, Florida
| | | | - Georgio Frank
- Center of Pituitary and Endoscopic Skull Base Surgery, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Center of Pituitary and Endoscopic Skull Base Surgery, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Garni Barkhoudarian
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Chester Griffiths
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Daniel Kelly
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | | | - Narayanan Janakiram
- Department of Otorhinolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus
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Whelehan DF, McCarrick CA, Ridgway PF. A systematic review of sleep deprivation and technical skill in surgery. Surgeon 2020; 18:375-384. [PMID: 32057670 DOI: 10.1016/j.surge.2020.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Dale F Whelehan
- Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
| | - Cathleen A McCarrick
- Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Paul F Ridgway
- Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
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Platte K, Alleblas CCJ, Inthout J, Nieboer TE. Measuring fatigue and stress in laparoscopic surgery: validity and reliability of the star-track test. MINIM INVASIV THER 2018; 28:57-64. [PMID: 29764260 DOI: 10.1080/13645706.2018.1470984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The star-track test has been assessed as valid and reliable to measure manual dexterity in the context of open surgery. We aimed to determine the construct validity and test-retest reliability of the star-track test for manual dexterity in a laparoscopic setting. MATERIAL AND METHODS The star-track test was performed in a laparoscopic box trainer. To determine construct validity an open-label, randomized four-period crossover trial was conducted. Alongside a baseline (non-interventional) measurement, interventions involved: physical fatigue, mental stress and a combination of these. The test-retest trial involved two separate (non-interventional) measurements. The primary outcome measures were accuracy, speed and manual dexterity (the integrated measure of accuracy and speed). RESULTS Participants made significantly more errors when physically fatigued, whereas participants performed the test significantly slower when mentally stressed. Manual dexterity was significantly affected in the case of combined intervention. High test-retest reliability was found for errors (ICC = 0.90) and completion time (ICC = 0.64). Fair test-retest reliability for the integrated measure was found (ICC = 0.37). CONCLUSION The star-track test is a valid and reliable tool to evaluate the effect of physical fatigue and/or mental stress on the characteristics of manual dexterity in a laparoscopic setting.
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Affiliation(s)
- Kim Platte
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Chantal C J Alleblas
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Joanna Inthout
- b Radboud Institute for Health Sciences , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Theodoor E Nieboer
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
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Effects of Fatigue Based on Electroencephalography Signal during Laparoscopic Surgical Simulation. Minim Invasive Surg 2018; 2018:2389158. [PMID: 29854453 PMCID: PMC5954867 DOI: 10.1155/2018/2389158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/30/2018] [Accepted: 02/21/2018] [Indexed: 11/30/2022] Open
Abstract
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 (DC), 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.
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