Background Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes. Methods We conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patient...

https://www.nejm.org/doi/pdf/10.1056/NEJMsa1300625

Surgical Skill and Complication Rates after Bariatric Surgery

Sources of Power: How People Make Decisions

Objective:The aim of this review was to summarize major topics in artificial intelligence (AI), including their applications and limitations in surgery. This paper reviews the key capabilities of AI to help surgeons understand and critically evaluate new AI applications and to contribute to new deve

/pdf/artificial-intelligence-in-surgery-promises-and-perils-4lwp28t731.pdf

Artificial Intelligence in Surgery: Promises and Perils

Background and purpose: The appropriate fixation method for
hemiarthroplasty of the hip as it relates to implant survivorship and patient mortality is a matter of ongoing debate. We examined the influence of fixation method on revision rate and mortality.----- -----
Methods: We analyzed approximately 25,000 hemiarthroplasty
cases from the AOA National Joint Replacement Registry. Deaths at 1 day, 1 week, 1 month, and 1 year were compared for all patients and among subgroups based on implant type.----- -----
Results: Patients treated with cemented monoblock hemiarthroplasty had a 1.7-times higher day-1 mortality compared to uncemented monoblock components (p < 0.001). This finding was reversed by 1 week, 1 month, and 1 year after surgery (p < 0.001). Modular hemiarthroplasties did not reveal a difference in mortality between fixation methods at any time point.----- -----
Interpretation: This study shows lower (or similar) overall
mortality with cemented hemiarthroplasty of the hip.

Perioperative mortality after hemiarthroplasty related to fixation method : a study based on the Australian Orthopaedic Association National Joint Replacement Registry

Extant ACT process measures are typically circumscribed in their focus (limited to particular theoretical sub-processes or contexts of application) and have been subject to critique in terms of their discriminant validity and conflation of process and outcome variables. Conceptual questions therefore remain regarding how best to operationalize and measure core ACT processes. In this study, we describe the development of a new general measure of ACT processes (the CompACT) and explore the measure's factor structure, validity and reliability. In phase one, ACT experts rated the face and content validity of 106 items using a Delphi consensus methodology, and produced an initial 37-itemed measure. In phase two, a non-clinical sample of participants (N = 377) completed the CompACT and measures of other theoretically related and unrelated variables. An exploratory factor analysis suggested a theoretically-coherent three-factor structure (clustering ACT's six processes into three dyadic processes) for a 23-itemed version of the CompACT. The CompACT demonstrated good internal consistency, and converged and diverged in theory-consistent ways with other measured variables: higher levels of psychological inflexibility were associated with higher levels of distress and lower levels of health and wellbeing. The CompACT shows initial promise as a general measure of ACT processes.

The development and validation of the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT)

available at http://www.ncbi.nlm.nih.gov/pubmed/25822691 Editorial Comment: The concept of surgical coaching is a relatively new idea to help improve training and education for surgeons and surgical residents. In this study 20 residents were ran- domized to undergo either 1) intense coaching during surgery, including ward and operating room duties, regular departmental sessions, performance analysis, debriefing, feedback and behavior modeling, or 2) standard conventional training. Video analysis of surgical resident performance was assessed in a blinded fashion. Residents with intensive surgical training scored higher in terms of procedural skills and made fewer technical errors during surgery. Thus surgical coaching, like coaching in sports and music, seems to benefit the surgeon in training, and one wonders if this is a model for future training.

Comprehensive Surgical Coaching Enhances Surgical Skill in the Operating Room: A Randomized Controlled Trial.

Background There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. Study Design The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. Results A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p Conclusions The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.

https://www.journalacs.org/article/S1072-7515(13)00026-4/pdf

Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery

Background

Surgical error analysis is essential for investigating mechanisms of errors, events and adverse outcomes. Furthermore, it provides valuable information for formative feedback and quality control. The aim of the present study was to design and validate a technical error rating tool in laparoscopic surgery.



Methods

The framework consisted of nine task groups and four error modes. Unedited videos of laparoscopic Roux-en-Y gastric bypass procedures were rated and analysed. The Objective Structured Assessment of Technical Skill (OSATS) global rating scale was used to assess technical skills. The incidence of errors and of injuries (events) were the main outcome measures, and were used to calculate the reliability, and construct and concurrent validity of the instrument.



Results

Two observers analysed 25 procedures. Inter-rater reliability was high regarding total number of errors (intraclass correlation coefficient (ICC) 0·90) and events (ICC 0·85). The median (interquartile range) error rate was 35 (26–44) and the event rate 3 (2–3) per procedure. Error frequencies and OSATS scores correlated significantly in all operative steps (rs = − 0·75 to −0·40, P = < 0·001–0·046). Surgeons demonstrating high OSATS scores had lower median (i.q.r.) error rates than surgeons with low scores in three of four steps: measuring bowel (4 (2–7) versus 10 (9–11); P = 0·004), jejunojejunostomy formation (5 (2–6) versus 10 (9–11); P = 0·001) and pouch formation (4 (3–6) versus 9 (5–12); P = 0·004).



Conclusion

The proposed error rating tool allows an objective and reliable assessment of operative performance in laparoscopic gastric bypass procedures.

Error rating tool to identify and analyse technical errors and events in laparoscopic surgery.

Background Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes.

Objective Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures.

Methods Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases.

Results Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were ‘inadequate use of force/distance (too much)’ (n=20, 30%) and ‘inadequate visualisation’ during grasping/dissecting (n=6, 9%), ‘inadequate use of force/distance (too much)’ using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively.

Conclusions Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons’ understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.

https://qualitysafety.bmj.com/content/qhc/24/8/516.full.pdf

Esther M. Bonrath

Papers

Comprehensive Surgical Coaching Enhances Surgical Skill in the Operating Room: A Randomized Controlled Trial.

Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery

Error rating tool to identify and analyse technical errors and events in laparoscopic surgery.

Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis

Teaching nontechnical skills in surgical residency: A systematic review of current approaches and outcomes