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Biomedical subjects

Krishna Moorthy

Publications and source records attributed to Krishna Moorthy.

At least 19 recordsLinked to original sources
PubMed2006

Objective assessment of small bowel anastomosis skill in trainee general surgeons and urologists.

INTRODUCTION: The object of this study was to compare the technical ability of general surgery and urology trainees to perform a small bowel anastomosis using a life-like bench model. METHODS: Forty subjects were divided into two groups based on the stage of their training. Specialist registrars (SpRs) trained for 1 to 3 years were defined as junior SpRs, and those with 4 to 6 years of training were defined as senior SpRs. They were asked to perform a small bowel anastomosis on a standard latex model using the same equipment, suture material, and standardized instructions. Trainees were assessed by three trained observers based on a global rating scale. RESULTS: Interrater reliability was 0.83 for the general surgical group and 0.88 for the urology group. The median scores obtained by the junior SpRs were lower than those achieved by the senior SpRs, and general surgical trainees consistently performed better than their matched urology group. This difference reached statistical significance for the senior group. CONCLUSIONS: Global rating scores provide a reliable, valid method for assessing technical skills between specialties when performing a small bowel anastomosis. We provide reasons why general surgeons may be more proficient at this task than urologists. These findings have possible application to identifying trainees who need additional training and may also provide a mechanism to ensure competence in this task.

Adult↗
PubMed2006

The effects of stress on surgical performance.

BACKGROUND: Although the general literature on stress and performance is extensive, little is known about specific effects of stress in surgical practice. This qualitative study explored key surgical stressors, their impact on performance, and coping strategies used by surgeons. METHODS: Individual in-depth semistructured interviews with surgeons were analyzed by 2 researchers independently. Key themes were discussed within the research team. RESULTS: Sixteen interviews were performed, including interviews with consultants (n = 9) and surgeons in training (n = 7). A wide range of intraoperative stressors was identified. Although stress had both positive and negative effects, undue levels of stress impaired judgment, decision making, and communication. Although junior surgeons showed uncertainty about their ability to cope, senior surgeons had developed sophisticated strategies for controlling each situation. CONCLUSIONS: Although stress poses significant risks, coping strategies are not taught explicitly during surgical training. This article presents a framework for categorizing surgical stress and suggests key elements for effective coping strategies.

Adaptation, Psychological↗
PubMed2006

Self-assessment of performance among surgical trainees during simulated procedures in a simulated operating theater.

BACKGROUND: The ability of surgeons to assess their own performance is essential for training and self-regulation. The latter is based on the premise that they recognize their weaknesses and seek remedial action accordingly. METHODS: Twenty-seven surgical trainees performed a simulated saphenofemoral high-tie on a synthetic model in a simulated operating theater. The performance assessment consisted of blinded rating of technical skills and a global rating of team skills by a human factors expert and a trained surgical research fellow. Subjects also were asked to assess their own performance using the same methods. Spearman's rho was used for data analysis. RESULTS: There was a strong correlation between the experts rating of technical skills and self-assessment (rho = .64). However, the correlation improved with increasing experience. It was .24 for junior trainees, .43 for those with intermediate experience, and .52 for senior trainees. There was a low correlation between the self-assessment and the expert scores for human factors skills (rho = .31). The correlation was higher for the 2 junior groups compared with the senior trainees. CONCLUSIONS: Unlike other studies on self-assessment, this study found that senior surgical trainees are accurate in their self-assessment of technical skills. However, this was not true in the case of human factors skills.

Clinical Competence↗
PubMed2006

A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill.

BACKGROUND: Studies have demonstrated the beneficial effect of training novice laparoscopic surgeons using virtual reality (VR) simulators, although there is still no consensus regarding an optimal VR training curriculum. This study aims to establish and validate a structured VR curriculum to provide an evidence-based approach for laparoscopic training programmes. METHODS: The minimally invasive VR simulator (MIST-VR) has 12 abstract laparoscopic tasks, each at 3 graduated levels of difficulty (easy, medium, and hard). Twenty medical students completed 2 sessions of all tasks at the easy level, 10 sessions at the medium level, and finally 5 sessions of the 2 most complex tasks at the hard level. At the medium level, subjects were randomized into 2 equal groups performing either all 12 tasks (group A) or the 2 most complex tasks (group B). Performance was measured by time taken, path length, and errors for each hand. The results were compared between groups, and to those of 10 experienced laparoscopic surgeons. RESULTS: Baseline performance of both groups was similar at the easy level. At the medium level, learning curves for all 3 parameters reached plateau at the second (group A, P < .05) and sixth (group B, P < .05) repetitions. Performance at the hard level was similar between the 2 groups, and all achieved the pre-set expert criteria. CONCLUSION: A graduated laparoscopic training curriculum enables trainees to familiarise, train and be assessed on laparoscopic VR simulators. This study can aid the incorporation of VR simulation into established surgical training programmes.

Adolescent↗
PubMed2006

Technical skills continue to improve beyond surgical training.

BACKGROUND: There is growing focus on surgical technical competence and the means by which we are able to measure it. Ongoing studies have shown a plateau effect with increasing experience of the operator. The aim of this study was to assess the technical competence of five groups of surgeons with increasing experience and validate a new rating tool for use in surgical assessment. METHODS: Fifty surgeons performed a saphenofemoral junction ligation on a synthetic groin model. The procedure was videotaped, blinded, and reviewed independently by three assessors. Performance was assessed using a previously validated global rating scale of generic surgical skill. In addition, each procedure was rated with the procedure-specific Imperial College Evaluation of Procedure-Specific Skill (ICEPS) rating scale to establish the construct validity (ability to differentiate on the basis of skill) and inter-observer reliability. RESULTS: Both rating scales showed improved scores with ascending grades (P < .001) and demonstrated a high inter-observer reliability both for generic and procedure-specific skill (alpha = 0.97 and alpha = 0.96, respectively). Total operative scores demonstrated significant differences between surgeons in postgraduate years 1 and 2 and surgeons in years 3 and 4 and also between newly appointed and experienced consultants (P < .041). Procedure-specific performance showed a plateau effect at the registrar level. Generic skill continued to improve, and significant differences were seen between newly appointed and senior consultants (P < .026). CONCLUSION: This study shows that surgical performance continues to improve significantly beyond consultancy, and the data suggest that generic and procedural performance continue to improve, with significant improvement in the former with increasing experience. The ICEPS rating scale demonstrates construct validity and a high inter-observer reliability supporting its use in formative and summative assessment.

Clinical Competence↗
PubMed2006

Training junior operative residents in laparoscopic suturing skills is feasible and efficacious.

BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation.

General Surgery↗
PubMed2006

Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance.

BACKGROUND: Intraoperative surgical crisis management is learned in an unstructured manner. In aviation, simulation training allows aircrews to coordinate and standardize recovery strategies. Our aim was to develop a surgical crisis simulation and evaluate its feasibility, realism, and validity of the measures used to assess performance. METHODS: Surgical trainees were exposed to a bleeding crisis in a simulated operating theater. Assessment of performance consisted of a trainee's technical ability to control the bleeding and of their team/human factors skills. This assessment was performed in a blinded manner by 2 surgeons and one human factors expert. Other measures consisted of time measures such as time to diagnose the bleeding (TD), inform team members (TT), achieve control (TC), and close the laceration (TL). Blood loss was used as a surrogate outcome measures. RESULTS: There were considerable variations within both senior (n = 10) and junior (n = 10) trainees for technical and team skills. However, while the senior trainees scored higher than the juniors for technical skills (P = 0.001), there were no differences in human factors skills. There were also significant differences between the 2 groups for TD (P = 0.01), TC (P = 0.001), and TL (0.001). The blood loss was higher in the junior group. CONCLUSIONS: We have described the development of a novel simulated setting for the training of crisis management skills and the variability in performance both in between and within the 2 groups.

Blood Loss, Surgical↗
PubMed2005

Synchronized video and motion analysis for the assessment of procedures in the operating theater.

HYPOTHESIS: Objective assessment of surgical skill has recently been shown to be possible through the use of dexterity-based and video analysis systems. The aim of this study was to synchronize these 2 modalities to produce a comprehensive surgical assessment tool. DESIGN: The Imperial College Surgical Assessment Device is a dexterity-based motion analysis device that has been developed in the Department of Surgical Oncology and Technology by the Surgical Computing and Imaging Research Group. Further advances to this system have been made to enable synchronized acquisition of hand kinematics and video from real procedures, and their concurrent analysis. To test the feasibility of the system, 10 laparoscopic cholecystectomies performed by 5 different surgeons on consenting patients were recorded. Analysis focused on the entire procedure and also on specific parts of the operation such as the clipping and cutting of the cystic duct and artery. RESULTS: Dexterity analysis was performed using the objective measures of time, path length, number of movements, velocities, and trajectories. Comparative analysis of a surgeon's dexterity was carried out on the whole procedure and by using the synchronized zoom facility in the software. Kinematic signals revealed rapid changes in velocity caused by alternating between different instruments or occurring after complications such as bleeding. CONCLUSION: This new motion analysis system has been shown to be an effective tool for the comprehensive assessment of operative procedures.

Cholecystectomy, Laparoscopic↗
PubMed2005

The reliability of multiple objective measures of surgery and the role of human performance.

BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.

Clinical Competence↗
PubMed2005

Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses.

BACKGROUND: Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. METHODS: Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. RESULTS: Overall, trainees made significant improvements in path length (P=.006), number of movements (P<.001), and time taken (P<.001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. DISCUSSION: Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy.

Cholecystectomy, Laparoscopic↗
PubMed2005

A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.

BACKGROUND: High-risk organizations such as aviation rely on simulations for the training and assessment of technical and team performance. The aim of this study was to develop a simulated environment for surgical trainees using similar principles. METHODS: A total of 27 surgical trainees carried out a simulated procedure in a Simulated Operating Theatre with a standardized OR team. Observation of OR events was carried out by an unobtrusive data collection system: clinical data recorder. Assessment of performance consisted of blinded rating of technical skills, a checklist of technical events, an assessment of communication, and a global rating of team skills by a human factors expert and trained surgical research fellows. The participants underwent a debriefing session, and the face validity of the simulated environment was evaluated. RESULTS: While technical skills rating discriminated between surgeons according to experience (P = 0.002), there were no differences in terms of the checklist and team skills (P = 0.70). While all trainees were observed to gown/glove and handle sharps correctly, low scores were observed for some key features of communication with other team members. Low scores were obtained by the entire cohort for vigilance. Interobserver reliability was 0.90 and 0.89 for technical and team skills ratings. CONCLUSIONS: The simulated operating theatre could serve as an environment for the development of surgical competence among surgical trainees. Objective, structured, and multimodal assessment of performance during simulated procedures could serve as a basis for focused feedback during training of technical and team skills.

Attention↗
PubMed2004

Robotic assisted rectopexy.

BACKGROUND: During the last 3 years, robotic surgery has had a considerable impact on minimally invasive surgery in a wide range of specialties. This study describes the surgical technique and preliminary results of our first 6 cases of robotic assisted suture rectopexy. METHODS: During a period of 13 months 6 patients with full thickness rectal prolapse were operated on with the da Vinci surgical system. All patients were considered suitable for a suture rectopexy. Setting-up time, procedure time, patient recovery, and hospital stay were recorded and compared with the current literature. RESULTS: All operations were completed successfully using the robotic system. There were no major complications and no deaths. Mean setting-up time was 28 minutes, mean operation time was 127 minutes, and mean hospital stay was 6 days. At 3 to 6 months of follow-up all patients are in good health, with no signs of recurrence and no reports of constipation. CONCLUSIONS: Robotic assisted suture rectopexy is feasible and safe and apparently meets accepted standards of laparoscopic surgery.

Adult↗
PubMed2004

Factors that predict conversion in patients undergoing laparoscopic surgery for Crohn's disease.

BACKGROUND: To identify factors that would predict conversion in patients undergoing laparoscopic surgery for Crohn's disease. METHODS: Data were collected retrospectively. All procedures were performed by an experienced laparoscopic surgeon. RESULTS: Forty-eight patients underwent 57 laparoscopic procedures. Twenty-six of these procedures were for recurrent disease. The conversion rate was 42.3% (11 of 26) for recurrent disease and 13% (4 of 31) for primary disease. On univariate analysis age (P = 0.02), surgery for recurrence (P = 0.02), time from diagnosis (P = 0.03), and the presence of a clinical mass (P = 0.03) were factors that predicted conversion. On multivariate analysis these factors except time from diagnosis still remained significant. Patients who did not undergo a conversion had significantly better post operative outcomes. There was no difference in the incidence of major or minor complications or the number of resections in both groups. CONCLUSIONS: The conversion rate for the whole group was 28%. The rate is higher in patients who are over 40 years of age who are undergoing procedures for recurrence.

Adult↗
PubMed2004

Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees?

BACKGROUND: It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery. METHODS: Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration. RESULTS: The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33). CONCLUSIONS: In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.

Analysis of Variance↗
PubMed2004

Ceiling effect in technical skills of surgical residents.

BACKGROUND: Objective evaluation of technical skills is now possible. The aim of this study was to evaluate whether a previously validated assessment tool can discriminate between junior and senior higher surgical trainees (HST) with regard to their technical skills. METHODS: Fifteen junior trainees (years 1 to 3) and 15 senior (years 4 to 6) were asked to perform a series of bench-model tasks, which included knot-tie at depth, vertical mattress suturing, sebaceous cyst excision, small bowel anastomosis, and saphenofemoral junction dissection. Analysis of performance included the Imperial College Surgical Assessment Device, which analyzed positional data such as total number of movements, total distance traveled, and time taken, and video-based qualitative evaluation of performance using global rating scales. In addition, all participants were asked to complete a self-assessment using exactly the same scoring system used by the observers. Statistical analysis included nonparametric tests and Cronbach's alpha was used for interrater reliability (IRR) A P value less than 0.05 was deemed significant. RESULTS: There were no significant differences in performance between junior and senior trainees for most of the tasks (IRR was 0.8 to 0.9). However, significant differences in performance were noted, in favor of the junior group, for knot-tie at depth, for two of the three parameters measured (total number of movements, P = 0.004; time taken, P = 0.01). CONCLUSIONS: In the absence of any significant differences between the groups, we can conclude that there is a ceiling effect (years 3 to 4) in performance beyond which pure technical skills, as measured by this tool, can no longer discriminate between levels of experience. Increasing the sensitivity of future assessment tools is necessary for better evaluation of performance levels. This finding also may imply that for the evaluation of senior trainees, other aspects of surgical competence should be assessed.

Adult↗
PubMed2004

Systems approaches to surgical quality and safety: from concept to measurement.

OBJECTIVE: This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. SUMMARY BACKGROUND DATA: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. METHODS: Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an "operation profile" to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.

General Surgery↗
PubMed2004

Real-time synchronization of kinematic and video data for the comprehensive assessment of surgical skills.

Surgical dexterity in operating theatres has traditionally been assessed subjectively. Electromagnetic (EM) motion tracking systems such as the Imperial College Surgical Assessment Device (ICSAD) have been shown to produce valid and accurate objective measures of surgical skill. To allow for video integration we have modified the data acquisition and built it within the ROVIMAS analysis software. We then used ActiveX 9.0 DirectShow video capturing and the system clock as a time stamp for the synchronized concurrent acquisition of kinematic data and video frames. Interactive video/motion data browsing was implemented to allow the user to concentrate on frames exhibiting certain kinematic properties that could result in operative errors. We exploited video-data synchronization to calculate the camera visual hull by identifying all 3D vertices using the ICSAD electromagnetic sensors. We also concentrated on high velocity peaks as a means of identifying potential erroneous movements to be confirmed by studying the corresponding video frames. The outcome of the study clearly shows that the kinematic data are precisely synchronized with the video frames and that the velocity peaks correspond to large and sudden excursions of the instrument tip. We validated the camera visual hull by both video and geometrical kinematic analysis and we observed that graphs containing fewer sudden velocity peaks are less likely to have erroneous movements. This work presented further developments to the well-established ICSAD dexterity analysis system. Synchronized real-time motion and video acquisition provides a comprehensive assessment solution by combining quantitative motion analysis tools and qualitative targeted video scoring.

Biomechanical Phenomena↗