Showing papers by "Rajesh Aggarwal published in 2013"

Virtual reality training for surgical trainees in laparoscopic surgery

Abstract: Background Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known. Objectives To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012. Selection criteria We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery. Data collection and analysis Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis. Main results We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group. Authors' conclusions Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

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

Abstract: 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.

Unannounced in situ simulations: integrating training and clinical practice

Abstract: Simulation-based training for healthcare providers is well established as a viable, efficacious training tool, particularly for the training of non-technical team-working skills. These skills are known to be critical to effective teamwork, and important in the prevention of error and adverse events in hospitals. However, simulation suites are costly to develop and releasing staff to attend training is often difficult. These factors may restrict access to simulation training. We discuss our experiences of ‘in situ’ simulation for unannounced cardiac arrest training when the training is taken to the clinical environment. This has the benefit of decreasing required resources, increasing realism and affordability, and widening multidisciplinary team participation, thus enabling assessment and training of non-technical team-working skills in real clinical teams. While there are practical considerations of delivering training in the clinical environment, we feel there are many potential benefits compared with other forms of simulation training. We are able to tailor the training to the needs of the location, enabling staff to see a scenario that is relevant to their practice. This is particularly useful for staff who have less exposure to cardiac arrest events, such as radiology staff. We also describe the important benefit of risk assessment for a clinical environment. During our simulations we have identified a number of issues that, had they occurred during a real resuscitation attempt, may have led to patient harm or patient death. For these reasons we feel in situ simulation should be considered by every hospital as part of a patient safety initiative.

Identifying and addressing preventable process errors in trauma care

Abstract: Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions.

Operating room of the future

Abstract: Development of surgical care in the 21st century is increasingly dependent on demonstrating safety, efficacy and cost effectiveness. Over the past 2 decades, the potential role of simulation in surgery has been explored with encouraging results; this can now be linked to direct improvement in the quality of care provision. Computer-assisted surgical platforms, such as robotic surgery, offer us the versatility to embrace a host of technical and technological developments. Rapid development in nanomedicine will expand the limits of operative performance through improved navigation and surgical precision. Integration of the multiple functions of the future operating room will be essential in optimising resource management. The key to bringing about the necessary paradigm shift in the design and delivery of modern surgical care is to appreciate that we now function in an information age, where the integrity of processes is driven by apt data management.

Implementation of an interactive virtual-world simulation for structured surgeon assessment of clinical scenarios.

Abstract: Background A novel simulation technology has emerged through the use of online 3-dimensional virtual worlds in which it is feasible to create virtual patients. This study establishes the face, content and construct validity of online 3-dimensional virtual patients in Second Life (a 3-dimensional virtual world accessible via the Internet). Study Design Sixty-three surgeons of the following grades participated in this study: intern (n = 20); junior resident (n = 15); senior resident (n = 18), and attending (n = 10). All subjects assessed a series of 3 virtual patients (level 1) with different surgical presentations, such as lower gastrointestinal bleeding, acute pancreatitis, and small bowel obstruction. The junior resident group managed an additional 3 cases (level 2) with the same presentation but of increasing complexity. The senior resident and attending groups completed a total of 9 cases (level 1 to 3). The primary outcomes measures were the face and content validity rated on a 7-point Likert scale and a performance score based on a performance rating. Results The simulation demonstrated high face and content validity ratings. Eight of 9 cases, with the exception of the level 3 small bowel obstruction, demonstrated significant differences in performance among the user groups (p Conclusions This novel form of simulation demonstrated high face and content validity. Performance assessed in managing a series of virtual patients varies with different levels of surgical training. This simulation can be used to differentiate among these levels and can be implemented as a unique form of assessment.

Toward technology-supported surgical training: the potential of virtual simulators in laparoscopic surgery.

Abstract: Background and Aims:The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to mov...

Simulation for ward processes of surgical care.

Abstract: The role of simulation in surgical education, initially confined to technical skills and procedural tasks, increasingly includes training nontechnical skills including communication, crisis management, and teamwork. Research suggests that many preventable adverse events can be attributed to nontechnical error occurring within a ward context. Ward rounds represent the primary point of interaction between patient and physician but take place without formalized training or assessment. The simulated ward should provide an environment in which processes of perioperative care can be performed safely and realistically, allowing multidisciplinary assessment and training of full ward rounds. We review existing literature and describe our experience in setting up our ward simulator. We examine the facilities, equipment, cost, and personnel required for establishing a surgical ward simulator and consider the scenario development, assessment, and feedback tools necessary to integrate it into a surgical curriculum.

A Cadaveric Porcine Model for Assessment in Laparoscopic Bariatric Surgery—a Validation Study

Abstract: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective surgical therapy for morbid obesity It is an advanced laparoscopic surgical procedure and has a protracted learning curve Therefore, it is important to develop innovative ways of training and assessing surgeons The aim of this study is to determine if a cadaveric porcine jejuno-jejunostomy model is an accurate way of assessing a surgeon's technical skills by determining if a correlation exists with how he performs in the operating room Eight surgeons of varying experience performed a side-to-side stapled jejuno-jejunostomy on a cadaveric bench model before proceeding to perform the procedure on a real patient scheduled for LRYGBP Performance was assessed using a motion tracking device, the Imperial College Surgical Assessment Device Each procedure was recorded in video and scored by two blinded expert surgeons using procedure-specific rating scales The cadaveric bench model demonstrated concurrent validity with significant correlations between performance on the cadaveric model and patient for dexterity measures Left-hand path length, r = 0857 (median, 27, 413; P = 0007), right-hand path length, r = 0810 (median, 315, 60; P = 0015) and total number of movements, r = 0743 (median, 422, 637; P = 0035) This correlation in performance was also demonstrated in the video rating scales, r = 0727 (median, 132, 148; P = 0041) No correlation was found in operative time (median, 541, 742; P = 0071) This study demonstrates the concurrent validity of the cadaveric porcine model, showing similar performances in surgeons completing a jejuno-jejunostomy on the cadaveric model and the patient

Surgical ward round quality and impact on variable patient outcomes

Abstract: Objective:To investigate the relationship between variability in surgical ward round (WR) quality and clinical outcomes.Background:Evidence increasingly suggests that ward-based care plays a key role in surgical outcomes. The WR is the focal point of surgical inpatient care. Assimilating various sou

A randomized controlled trial evaluating endoscopic and laparoscopic training in skills transfer for novices performing a simulated NOTES task.

Abstract: Background. The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task. Methods. A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors. Results. The endoscopy group was significantly faster than the control group at accessing the peri...

Defining quality in surgical training: perceptions of the profession

Abstract: BACKGROUND: To improve surgical training standards, it is necessary to first define the elements of high-quality training and methods for measuring them. METHODS: Semistructured interviews were conducted with attending (n 5 10) and resident (n 5 10) general surgeons.Aninterviewtopic guidewasused toelicitend users’ opinionsonindicators oftraining quality and methods to measure them. Interviews were recorded, transcribed verbatim,and coded using a framework to identify emergent themes. Sampling ceased once thematic saturation was achieved. RESULTS: Key surgical training quality indicators include continuity (80% of participants) and relationship (95%) between trainee and trainer, level of supervision (85%), and an optimal volume (95%) and mix (90%) of operative cases. All surgeons felt that trainee logbook analysis and feedback was essential. The majority (85%) felt that training analysis should be freely available to create accountability for hospitals and attending surgeons (70%) and encourage competition (70%) to drive up standards. Only 30% felt that all attending surgeons should offer training. CONCLUSIONS: Surgical training quality needs to be robustly assessed. Transparency in training outcomes will create competition and raise standards of surgical education.

Re: Consumer-based technology for distribution of surgical videos for objective evaluation.

Abstract: We commend the authors of “Consumer-based technology for distribution of surgical videos for global evaluation” for utilizing easily accessible equipment as a means to distribute videos for evaluation of technical skill [1]. Given the ubiquity of mobile devices and the cumbersome nature of handling DVD multimedia, video distribution through mobile-enabled, web-based services certainly improves access to videos for assessment, feedback, quality control, and medical record keeping. Facilitating access to surgical videos raises three key concerns based upon data security and privacy. First, even when patient or surgeon identities are not apparent from video images, potentially identifying information such as time and location of the operation can be bundled with the video files in the form of metadata. Second, standards of security and privacy may be inconsistent among parties sending and receiving data. Finally, the results of skill evaluation are highly sensitive information given their potential implications for surgeon accreditation and malpractice. Thus, it is worth considering whether surgeons should also be given the ability to opt out of sharing their procedure videos with third parties. Quality of surgical practice is essential to patient safety, yet current methods of assessing surgical quality often focus on outcome measures which, though effective, provide only an incomplete picture of surgical quality and performance. Comparing surgical performance to elite athletics, consider that while the final score of a basketball game may reflect the winner, only a breakdown of each quarter and player can give a complete picture of how the game was won. Similarly, process measures assessed through means such as objective evaluation of video may be a valuable resource to highlight areas of good performance and identify deficiencies to correct. The authors effectively demonstrate how advances in information technology will aid the surgical community as we strive to develop practical, meaningful methods for assessing surgical skill. However, we must continue to protect patient and surgeon privacy rights as skill assessment enters the 21st century.

Call-associated Acute Fatigue in Surgical Residents—Subjective Perception or Objective Fact? A Cross-sectional Observational Study to Examine the Influence of Fatigue on Surgical Performance

Abstract: Letters to the Editor We read with interest the article by Schlosser et al. regarding the impact of acute sleep deprivation on technical and cognitive skills [1]. The objective appraisal of the impact of sleep deprivation on technical and cognitive skills will contribute toward a more informed discussion of a complex subject. In a recent systematic review of the impact of fatigue resulting from sleep deprivation, the authors highlighted the equivocal nature of the current evidence base [2]. Prior to the assessment of the impact of a set of conditions, the variables must be clearly defined and standardized at the pre-interventional stage. The authors do not present data regarding the proficiency of the participants prior to the commencement of the study [1]. Although each participant had to ‘‘successfully perform’’ ten sessions of the basic tasks and five sessions of the advanced tasks, we cannot elicit whether each participant had reached a proficiency benchmark or arrived at the plateau of their learning curve. The post-call improvement in technical skills noted within the ‘‘cutting’’ task, intracorporeal suturing, and cholecystectomy tasks may represent an ongoing ‘‘learning effect.’’ In order to nullify this effect, participants should either employ a validated curriculum for training or demonstrate that they have reached the plateau for a given task [3]. Among the most experienced group, the learning effect would be expected to be either minimal or absent. Interestingly, within each of the three groups, sleep deprivation has no impact on the technical performance for the ‘‘cutting’’ task. Further, the categorization of participants into three subgroups is based on training grade only; an indication of participants’ level of operative experience will further assist in minimizing heterogeneity within subgroups [4]. Although direct performance assessment (e.g., dexterity analysis) is a recognized modality in analyzing the cognitive burden, ‘‘secondary task’’ measures and physiological studies will be important tools in eliciting a more complete understanding of the impact of sleep deprivation on surgical performance [5].

031 admission at nights or weekends has no adverse effect on mortality for st elevation myocardial infarction patients treated by primary percutaneous coronary intervention

Abstract: Introduction Mortality amongst emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. We studied the mortality for STEMI patients presenting at different times to a large cardiothoracic centre in the UK with a 24/7 primary PCI (PPCI) service delivered by senior medical staff. Methods We included all patients who underwent PPCI from September 2009 to November 2011. We divided them into three groups according to the time of admission to our unit as group 1: in-hours (08:00–18: weekdays), group 2: out-of-hours (18:00–08:00 week nights) and group 3: weekend (Saturday 08:00 to Monday 08:00) and bank holidays. Results Of the 1471 patients who were admitted and underwent PPCI in our unit during the study period, 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3 respectively. Pre-procedure cardiogenic shock was significantly higher in group 1 compared to group 2 (8.9% vs 5.5%, p 0.05), but no other significant difference was noted in the baseline and procedural characteristics between the groups (table 1). When compared to group 1, door to balloon (DTB) time (median, IQR 29, 24–39 min) was significantly prolonged in group 2 (33, 24–36 min, p 0.004) and group 3 (36, 28–47 min, p Conclusions In this consecutive series of patients admitted to a high volume primary PCI centre, there was no difference in mortality when patients were admitted at night, at the weekend or during regular office hours. The involvement of senior medical staff early in the patients9 admission may have contributed to these consistent outcomes.

In reference to Objective assessment in residency‐based training for transoral robotic surgery

Abstract: We thank the readers for their careful consideration and review of our study and are encouraged by their sincere feedback. To update the readers, we are now preparing the next iteration of a curricular resident training protocol and have expanded the training beyond the base of tongue resection already published. We expect to provide the community with additional publications and updates when the next iteration is complete and results are available. In addition, our methods (and even equipment and resources where possible) are now available to the research community. Our work has also been reviewed by the Minimally Invasive Robotic Association Fundamentals of Robotic Surgery workgroup, and we have provided didactic input to that effort, which might someday be the accepted credentialing platform across specialties. In addition, we continue to mine our data for additional insights. With respect to the specific suggestions made by the readers, they are good advice for any research study. However, the presented study was well controlled for the effects of additional instruction. No instruction for the specific training tasks was provided during the training modules, and no additional disclosures are needed. We do agree that reviewing the design for needed controls and sources of bias is sound advice for any research study. We disagree with the interpretation and commentary on interobserver agreement. Our reviewers were well trained with pregraded example studies, and the rater training process was sound. The 0.8 “good” level (noted in the readers’ letter) finds little support in broader analysis, and we used broadly accepted levels to classify our variability results. The levels measured are suitable for instructional use. We further note that these statistics (will) continue to evolve with data from additional protocols (both users and raters), and we will report such updates when available. It was not an aim of the study to improve rater agreement, we merely reported the levels achieved in this iteration of the protocol. It must be emphasized that the order of detail and complexity of our measurements and analysis is orders of magnitude greater than previous reports, and a comparison may be moot to begin with. We note that learning curves reported are for an individual trainee over the considerable duration of the protocol and are compared with expert performance. The additional statistical analysis recommended, although relevant, deviates from the primary goals of the first iteration of our protocol. We aimed to establish performance baselines and verify the efficacy of measurement and analysis methods, and that expert baselines were achievable for our experimental tasks given the various constraints (including time available) for today’s trainees. In summary, we again thank the writers for their feedback. We will incorporate additional statistics, over additional raters and trainees, and over the following iterations of our protocol in follow-up publications. We also encourage this group, and other researchers planning curricular training, to both review and consider adopting our archival and analysis methods.