Training, efficiency and ergonomics in minimally invasive surgery

Knoopsgatchirurgie (laparoscopie) heeft een aantal bewezen voordelen voor de patiënt. Voor het operatieteam gaat er een aantal uitdagingen gemoeid met deze manier van opereren. Met name op het gebied van de ergonomie en de efficiëntie van het operatieproces en op het gebied van training van chirurgen die deze techniek willen toepassen zijn verbeteringen nodig. Hierover gaat dit proefschrift. In deel 1 van dit proefschrift onderzoeken we wat de beste houding is om laparoscopische chirurgie te kunnen uitvoeren. Met name de positie van de monitor is daarbij van belang. De monitor dient ruim onder ooghoogte, dicht bij het operatieveld en in lijn met de werkrichting van de chirurg geplaatst te worden. We tonen aan dat een speciaal voor laparoscopie ontworpen operatiekamer een significante verbetering van de ergonomie en een verbeterde efficiëntie tussen de operaties door kan opleveren. In deel 2 van dit proefschrift onderzoeken we een nieuwe manier van proceduretraining op de operatiekamer. Een cohort assistenten doorloopt een curriculum voor laparoscopische galblaasoperaties. Nadat zij hun basisvaardigheden hebben geleerd op een simulator begonnen ze met proceduretraining op de operatiekamer. Gedurende 6 operaties kregen ze tijdens elke ingreep herhaaldelijk korte video-instructies over de volgende stap die moest worden uitgevoerd. Na het zien van de instructie mochten ze die stap van de operatie uitvoeren. De beoordelingen van de assistenten die op deze manier zijn getraind verbeterden sneller dan in een controle groep. We tonen aan dat deze methode effectief en uniform is terwijl de efficiëntie van het operatieproces niet benadeeld wordt

The Need for Objective Physical Activity Measurements in Routine Bariatric Care

PURPOSE: This study aims to (1) quantify physical behavior through self-reports and sensor-based measures, (2) examine the correlation between self-reported and sensor-based physical activity (PA) and (3) assess whether bariatric patients adhere to PA guidelines. METHODS: A Fitbit accelerometer was used to collect minute-to-minute step count and heart rate data for 14 consecutive days. Total physical activity levels (PAL), moderate-to-vigorous intensity physical activity (MVPA) and sedentary behavior (SB) were used to quantify physical behavior. Self-reported PA was assessed with the International Physical Activity Questionnaire (IPAQ). To analyze the association between sensor-based and self-reported PA, Spearman’s correlation was used. A minimum of 150 MVPA minutes per week was considered as compliance with the PA guidelines. RESULTS: Fitbit data of 37 pre- and 18 post-surgery patients was analyzed. Participants averaged 7403 ± 3243 steps/day and spent most of their time sedentary (832 min, IQR: 749 – 879), especially in prolonged periods of ≥ 30 min (525, IQR: 419 – 641). Median MVPA time was 5.6 min/day (IQR: 1.7 – 10.6). Correlations between self-reported and sensor-based MVPA and SB were respectively 0.072 and 0.455. Only 17.1% was objectively adherent to MVPA guidelines ≥ 150 min/week, while 94.3% met the guidelines in case of self-reports. CONCLUSION: PA quantification confirmed that bariatric patients are highly sedentary and rarely engage in MVPA, despite a relatively high daily step count. Moreover, bariatric patients are not able to assess MVPA and moderately their SB by self-reports. Our results indicate the need for sensor-based PA monitoring in routine bariatric care. GRAPHICAL ABSTRACT: [Image: see text] SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11695-022-06165-y

Risk-Assessment of Esophageal Surgery:Diagnosis and Treatment of Celiac Trunk Stenosis

Anastomotic leakage of the gastric conduit following surgical treatment of esophageal cancer is a life-threatening complication. An important risk factor associated with anastomotic leakage is calcification of the supplying arteries of the gastric conduit. The patency of calcified splanchnic arteries cannot be assessed on routine computed tomography (CT) scans for esophageal cancer and, as such, in selected patients with known or assumed mesenteric artery disease, additional CT angiography of the abdominal arteries with 1mm slices is strongly encouraged. If the mesenteric perfusion is compromised in patients with resectable esophageal cancer, angioplasty procedures with stenting of the mesenteric arteries could be performed to prevent possible ischemia of the gastric conduit

Assessment methods in laparoscopic colorectal surgery:a systematic review of available instruments

Background: Laparoscopic surgery has become the golden standard for many procedures, requiring new skills and training methods. The aim of this review is to appraise literature on assessment methods for laparoscopic colorectal procedures and quantify these methods for implementation in surgical training. Materials and methods: PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in October 2022 for studies reporting learning and assessment methods for laparoscopic colorectal surgery. Quality was scored using the Downs and Black checklist. Included articles were categorized in procedure-based assessment methods and non-procedure-based assessment methods. A second distinction was made between capability for formative and/or summative assessment. Results: In this systematic review, nineteen studies were included. These studies showed large heterogeneity despite categorization. Median quality score was 15 (range 0–26). Fourteen studies were categorized as procedure-based assessment methods (PBA), and five as non-procedure-based assessment methods. Three studies were applicable for summative assessment. Conclusions: The results show a considerable diversity in assessment methods with varying quality and suitability. To prevent a sprawl of assessment methods, we argue for selection and development of available high-quality assessment methods. A procedure-based structure combined with an objective assessment scale and possibility for summative assessment should be cornerstones.</p

Assessment of Contraceptive Counseling and Contraceptive Use in Women After Bariatric Surgery

BACKGROUND: Reproductive-aged women are, according to American and European guidelines, recommended to avoid pregnancy for 12-24 months after bariatric surgery. Oral contraceptives may have suboptimal efficacy after malabsorptive bariatric procedures. AIM: The aim of this study was to assess contraceptive use pre- and postoperatively in women who underwent bariatric surgery in two obesity clinics in The Netherlands. Also, the recall of contraceptive and pregnancy counseling was investigated. METHODS: A validated questionnaire was performed among women aged 18-45 years who underwent bariatric surgery from October 2017 through August 2018. RESULTS: In total, 230 women were eligible for final analysis. Postoperatively, 60% used safe contraception, 16.1% unsafe contraception, and 23.9% no contraception. In this study, 43.7% of women using a potential unsafe contraceptive method preoperatively switched to a safe method of contraception postoperatively (p < 0.0001). Only 62.6% of women confirmed to have received contraceptive counseling, mainly preoperatively. The odds ratio for receiving contraceptive counseling and using safe contraceptive methods compared with not receiving contraceptive counseling was 2.20 (95% CI, 1.27-3.79; p = 0.005). Eighty-three percent confirmed that they have received counseling regarding delaying a pregnancy, and 52.6% were familiar with the recommendation to avoid a pregnancy for 24 months postoperatively. CONCLUSIONS: In our study, 60% of women are using safe contraception postoperatively. Contraceptive counseling is suboptimal as 62.6% recall receiving counseling. Those who confirmed receiving counseling were more likely to use safe contraception after bariatric surgery. More counseling and monitoring in the postoperative and in the outpatient setting is recommended

Validity, reliability and support for implementation of independence-scaled procedural assessment in laparoscopic surgery

Background There is no widely used method to evaluate procedure-specific laparoscopic skills. The first aim of this study was to develop a procedure-based assessment method. The second aim was to compare its validity, reliability and feasibility with currently available global rating scales (GRSs). Methods An independence-scaled procedural assessment was created by linking the procedural key steps of the laparoscopic cholecystectomy to an independence scale. Subtitled and blinded videos of a novice, an intermediate and an almost competent trainee, were evaluated with GRSs (OSATS and GOALS) and the independence-scaled procedural assessment by seven surgeons, three senior trainees and six scrub nurses. Participants received a short introduction to the GRSs and independence-scaled procedural assessment before assessment. The validity was estimated with the Friedman and Wilcoxon test and the reliability with the intra-class correlation coefficient (ICC). A questionnaire was used to evaluate user opinion. Results Independence-scaled procedural assessment and GRS scores improved significantly with surgical experience (OSATS p = 0.001, GOALS p <0.001, independence-scaled procedural assessment p <0.001). The ICCs of the OSATS, GOALS and independence-scaled procedural assessment were 0.78, 0.74 and 0.84, respectively, among surgeons. The ICCs increased when the ratings of scrub nurses were added to those of the surgeons. The independence-scaled procedural assessment was not considered more of an administrative burden than the GRSs (p = 0.692). Discussion/conclusion A procedural assessment created by combining procedural key steps to an independence scale is a valid, reliable and acceptable assessment instrument in surgery. In contrast to the GRSs, the reliability of the independence-scaled procedural assessment exceeded the threshold of 0.8, indicating that it can also be used for summative assessment. It furthermore seems that scrub nurses can assess the operative competence of surgical trainees

Procedure-based assessment for laparoscopic cholecystectomy can replace global rating scales

Introduction Global rating scales (GRSs) such as the Objective Structured Assessment of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Surgery (GOALS) are assessment methods for surgical procedures. The aim of this study was to establish construct validity of Procedure-Based Assessment (PBA) and to compare PBA with GRSs for laparoscopic cholecystectomy. Material and methods OSATS and GOALS GRSs were compared with PBA in their ability to discriminate between levels of performance between trainees who can perform the procedure independently and those who cannot. Three groups were formed based on the number of procedures performed by the trainee: novice (1-10), intermediate (11-20) and experienced (>20). Differences between groups were assessed using the Kruskal-Wallis and Mann-Whitney U tests. Results Increasing experience correlated significantly with higher GRSs and PBA scores (all p < .001). Scores of novice and intermediate groups overlapped substantially on the OSATS (p = .1) and GOALS (p = .1), while the PBA discriminated between these groups (p = .03). The median score in the experienced group was higher with less dispersion for PBA (97.2[85.3-100]) compared to OSATS (82.1[60.7-100]) and GOALS (80[60-100]). Conclusion For assessing skill level or the capability of performing a laparoscopic cholecystectomy independently, PBA has a higher discriminative ability compared to the GRSs