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PubMed1979

Dexterity testing and residents' surgical performance.

1. With some exceptions, those who choose ophthalmology as a career may approximate the general population in innate manual dexterity. 2. Many factors other than manual dexterity influence the development of surgical skills by residents. 3. If dexterity testing is to be used, the addition or inclusion of tests for spatial aptitudes may be more helpful than simple dexterity tests alone. The predictive value of such tests for surgical performance would need vertification. 4. The development of a special test directly related to handling surgical instruments, to cutting, and to sewing (the criteria) may be more practical than the ones used in this study.

Aptitude Tests↗
PubMed2000

Monitoring surgical performance using risk-adjusted cumulative sum charts.

The cumulative sum (CUSUM) procedure is a graphical method that is widely used for quality monitoring in industrial settings. More recently it has been used to monitor surgical outcomes whereby it 'signals' if sufficient evidence has accumulated that there has been a change in the surgical failure rate. A limitation of the standard CUSUM procedure in this context is that since it is simply based on the observed surgical outcomes, it may signal as a result of changes in the referral pattern, such as an increased proportion of high-risk patients, rather than due to a change in the actual surgical performance. We describe a new CUSUM procedure that adjusts for each patient's pre-operative risk of surgical failure through the use of a likelihood-based scoring method. The procedure is therefore ideally suited for settings where there is a variable mix of patients over time.

Journal Article↗
PubMed2003

An evaluation of existing risk stratification models as a tool for comparison of surgical performances for coronary artery bypass grafting between institutions.

OBJECTIVE: Risk stratification systems are used in cardiac surgery to estimate mortality risk for individual patients and to compare surgical performance between institutions or surgeons. This study investigates the suitability of six existing risk stratification systems for these purposes. METHODS: Data on 5471 patients who underwent isolated coronary artery bypass grafting at two UK cardiac centres between 1993 and 1999 were extracted from a prospective computerised clinical data base. Of these patients, 184 (3.3%) died in hospital. In-hospital mortality risk scores were calculated for each patient using the Parsonnet score, the EuroSCORE, the ACC/AHA score and three UK Bayes models (old, new complex and new simple). The accuracy for predicting mortality at an institutional level was assessed by comparing total observed and predicted mortality. The accuracy of the risk scores for predicting mortality for a patient was assessed by the Hosmer-Lemeshow test. The receiver operating characteristic (ROC) curve was used to evaluate how well a system ranks the patient with respect to their risk of mortality and can be useful for patient management. RESULTS: Both EuroSCORE and the simple Bayes model were reasonably accurate at predicting overall mortality. However predictive accuracy at the patient level was poor for all systems, although EuroSCORE was accurate for low to medium risk patients. Discrimination was fair with the following ROC areas: Parsonnet 0.73, EuroSCORE 0.76, ACC/AHA system 0.76, old Bayes 0.77, complex Bayes 0.76, simple Bayes 0.76. CONCLUSIONS: This study suggests that two of the scores may be useful in comparing institutions. None of the risk scores provide accurate risk estimates for individual patients in the two hospitals studied although EuroSCORE may have some utility for certain patients. All six systems perform moderately at ranking the patients and so may be useful for patient management. More results are needed from other institutions to confirm that the EuroSCORE and the simple Bayes model are suitable for institutional risk-adjusted comparisons.

Bayes Theorem↗
PubMed2005

Skill assessment of urological laparoscopic surgeons: can criterion levels of surgical performance be determined using the pelvic box trainer?

OBJECTIVES: To correlate between surgeons' experience in urological laparoscopy and their performance of a set of laparoscopic tasks performed on a box trainer in the laparoscopic laboratory. METHODS: 44 urologists participated in this study. A self-administrated questionnaire enquired about their experience in laparoscopy and they were divided to 4 categories: no experience, minimal experience, basic and advanced laparoscopists. Tests consisted of 4 tasks: passage of a ligature, intracorporeal knotting, intracorporeal suturing, and cutting a carton circle out of a square. All tests were supervised and time was recorded for each of the tasks. Histograms were plotted showing the mean time for performance of each task in each experience group. The Kruskal-Wallis analysis of variance was used to assess statistical significance. RESULTS: Seven participants had no previous experience in laparoscopy and 14 had minimal experience. 15 had basic experience and 8 were advanced laparoscopists. No difference in performance was found between the no experience and minimal experience group and they were united and defined as beginners. A significant difference in performance was noted between the beginners, basic and advanced groups, especially when comparing beginners to advanced. Criterion level values of surgical performance drawn from this data were highly discriminative with sensitivity of 71-85% and specificity of 74.2%-88%. CONCLUSIONS: We were able to differentiate between various levels of laparoscopic skills among the participating urologists. Values drawn from such studies could be the basis of criterion level values for technical laparoscopic performance during training programs and before granting laparoscopic privileges to urologists.

Adult↗
PubMed1980

Dose beta-blockade affect surgical performance? a double blind trial of oxprenolol.

Heart rates of surgeons rise when they carry out operations and this rise is abolished by beta-blockade. In an assessment of the effect of oxprenolol on surgical performance a group of surgeons took double blind either oxprenolol 40 mg or a matching placebo. Oxprenolol abolished increases in heart rate (P < 0.001) but had no effect on a profile of performance test assessing tremor, suturing accuracy and co-ordination. Reaction time of the surgeons was significantly slowed by oxprenolol (P < 0.01). Using a self-administered visual analogue scoring system the surgeons recorded no subjective changes in mood after beta-blockade and were surprisingly unaware of whether they had taken oxprenolol or placebo.

Attention↗
PubMed2002

Effects of a moderate dose of alcohol on simulated laparoscopic surgical performance.

BACKGROUND: In medicine, there is no professional regulation of the drinking of alcohol, nor a body of experimental evidence on which such regulation might be based. Here we report the acute and longer-term ("hangover") effects of a moderate dose of alcohol on performance, as assessed objectively on a laparoscopic surgical simulator. METHODS: In a single-blind, experimental study, medical student subjects were assigned randomly to an alcohol (1.05 mg/kg) or a placebo condition (n = 14 in each). The effects of alcohol on performance on the MIST Virtual Reality surgical simulator were examined 60-90 min and 600-630 min (after a night's sleep) following its ingestion. Measures of the number of errors, time taken, hand movement economy, and excessive use of diathermy were recorded. RESULTS: On each measure, performance was significantly impaired 60-90 min following alcohol ingestion, but there was no hangover effect 600-630 min later, following a night's sleep. This impairment could not be attributed to between-group differences in either predrink performance, expertise or estimated sleep duration during the night preceding the experimental session. CONCLUSIONS: Simulated surgical performance is impaired severely when estimated blood alcohol concentration (BAC) is just above the UK legal limit for driving. These results contribute new, objective and quantitative evidence to the current debate about the use and misuse of alcohol within the medical profession.

Adult↗
PubMed1998

The effect of propranolol versus placebo on resident surgical performance.

PURPOSE: To determine whether propranolol can decrease surgical tremor and anxiety in residents performing ocular microsurgery without impairing patient or physician safety. METHODS: In this randomized, double-masked, crossover study, 5 third-year ophthalmology residents ingested a capsule containing either propranolol, 40 mg, or placebo 1 hour prior to performing ophthalmic microsurgery. All residents were healthy men under age 30 years. Prior to commencement of the study, all participants had successfully been administered a test dose of propranolol without side effects. The study took place over a 10-week period. At the conclusion of each case, both the resident and attending surgeon observer independently completed a form grading, on a sliding scale: (1) amount of overall tremor; (2) amount of tremor during placement of the first 3 sutures after lens or nucleus extraction; (3) anticipated difficulty of the case; (4) actual difficulty with the case; and (5) anxiety (surgeon only). In addition, the type of procedure performed, complications encountered, and surgeon side effects were recorded. The data were analyzed with a 2-way analysis of variance for unbalanced data. RESULTS: A total of 73 surgical cases were performed; the surgeons were administered propranolol for 40 cases and placebo for 33. As judged by the resident surgeon, there was a highly significant effect of propranolol in decreasing anxiety (P = .0058), reducing surgical tremor overall (P < .0001), and reducing tremor while placing the first 3 sutures following lens extraction (P < .0001). There was no treatment-by-surgeon interaction for any of the measures. Complications and difficulty of the case, as judged by both the resident and attending surgeons, were not significantly different in the propranolol versus placebo groups (P > .05). There were no side effects reported or observed in any of the surgeons. CONCLUSIONS: Propranolol, 40 mg, administered 1 hour prior to surgery, significantly decreases tremor and anxiety in the surgeon without untoward effects to the surgeon and the patient. However, it is unknown whether decreased tremor and anxiety improved surgical outcome.

Adrenergic beta-Antagonists↗
PubMed2005

Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance.

BACKGROUND: Several studies have investigated the transfer of surgical trainees' skills acquired on surgical simulators to the operating room setting. The purpose of this study was to compare the effectiveness of two laparoscopic surgery simulators by assessing the transfer of skills learned on simulators to closely matched surgical tasks in the animal laboratory. STUDY DESIGN: In this post-test-only Control group study design, 46 surgically naive medical student volunteers were randomly assigned to one of three groups: Tower Trainer group (n = 16), LapSim group (n = 17), and Control group (n = 13). Outcomes measures included both time and accuracy scores on three laparoscopic tasks (Task 1: Grasp and Place; Task 2: Run the Bowel; Task 3: Clip and Cut) performed on live anesthetized pigs, and a global rating of overall performance as judged by four experienced surgeons. RESULTS: The Tower Trainer group performed significantly better than the Control group on 1 of 7 outcomes measures-Task 3: Time (p < 0.032), although the LapSim group performed significantly better than the Control group on 2 of 7 measures-Task 3: Time (p < 0.008) and Global score (p < 0.005). In comparing the two simulators, the LapSim group performed significantly better than the Tower Trainer group on 3 of 7 outcomes measures-Task 2: Time (p < 0.032), Task 2: Accuracy (p < 0.030) and Global score (p < 0.005), although the Tower Trainer group did not perform significantly better than the LapSim group on any measure. CONCLUSIONS: This study demonstrated that naive subjects trained on a virtual-reality part-task trainer performed better on live surgical tasks in a porcine model as compared with those trained with a traditional box trainer. These findings could aid in selection of appropriate training methodologies.

Adult↗
PubMedDate not supplied

[Surgical performance].

Explore the source record for details and available documents.

Cardiac Surgical Procedures↗
PubMed2004

Surgical mortality score: risk management tool for auditing surgical performance.

Existing methods of risk adjustment in surgical audit are complex and costly. The present study aimed to develop a simple risk stratification score for mortality and a robust audit tool using the existing resources of the hospital Patient Administration System (PAS) database. This was an observational study for all patients undergoing surgical procedures over a two-year period, at a London university hospital. Logistic regression analysis was used to determine predictive factors of in-hospital mortality, the study outcome. Odds ratios were used as weights in the derivation of a simple risk-stratification model-the Surgical Mortality Score (SMS). Observed-to-expected mortality risk ratios were calculated for application of the SMS model in surgical audit. There were 11,089 eligible cases, under five surgical specialties (maxillofacial, orthopedic, renal transplant/dialysis, general, and neurosurgery). Incomplete data were 3.7% of the total, with no evidence of systematic underreporting. The SMS model was well calibrated [Hosmer-Lemeshow C-statistic: development set (3.432, p = 0.33), validation set (6.359, p = 0.10) with a high discriminant ability (ROC areas: development set [0.837, S.E.=0.013] validation set [0.816, S.E. = 0.016]). Subgroup analyses confirmed that the model can be used by the individual specialties for both elective and emergency cases. The SMS is an accurate risk- stratification model derived from existing database resources. It is simple to apply as a risk-management, screening tool to detect aberrations from expected surgical outcomes and to assist in surgical audit.

Adult↗
PubMed1990

Medical audit: assessment of surgical performance in a low volume specialty.

We describe a simple technique for auditing one aspect of the activity of a neurosurgical unit--the surgical operations performed. A proforma completed by the surgeon at the time of operation was brought up-to-date on subsequent daily ward rounds. Each week, the medical staff of the unit met to review the data sheets of those patients discharged during the previous seven days. This meeting served to ensure the completeness of the data and to discuss any problems in management before the records were computerized. At the end of the first year, problems which had become apparent in the system were identified and corrected. The revised system involves a comprehensive and prospective audit of relevant clinical information. It has led to the accumulation of a considerable quantity of reliable data and it involves frequent positive feedback which appears to be leading to an improvement in treatment outcome. The system is simple to administer and is economical of time. It should be suitable for any surgical specialty which resembles neurosurgery in dealing with a relatively small volume of major procedures, and it could easily be adapted to audit other aspects of the activity of a unit.

Evaluation Studies as Topic↗
PubMed2005

Evaluation of surgical performance with standard rigid and flexible-tip laparoscopes.

BACKGROUND: Flexible-tip laparoscopes have recently been introduced into clinical practice, with the goal of improving surgeon performance during complex laparoscopic procedures. We used objective and subjective performance parameters to compare standard rigid 0 degrees and 30 degrees lens laparoscopes two flexible-tip laparoscopes in an in vitro model. METHODS: Twenty-nine subjects with varied levels of surgical experience performed complex laparoscopic tasks in three different models simulating (a) prostate dissection from the rectum, (b) cystic duct clipping, and (c) distal posterior rectum dissection. Each task was performed using two Storz rigid laparoscopes (0 degrees and 30 degrees) and two flexible-tip laparoscopes, the Olympus LTF-V3 and the Fujinon EL2-TF310. The sequence of application of the two flexible-tip laparoscopes was randomized. In each case, an experienced laparoscopic camera driver controlled the field of vision. Time to complete each task, operative precision, and subjective surgeon rating scores were compared. Statistical analysis was performed with analysis of variance (ANOVA) and a two-sided fisher's exact test. RESULTS: In all three models, the flexible laparoscopes offered no advantage in terms of procedure time, surgical precision, or subjective surgeon rating score when compared with the 30 degrees lens rigid laparoscope. The 30 degrees rigid lens laparoscope and the two flexible-tip laparoscopes were superior to the 0 degrees lens rigid laparoscope for all parameters evaluated, with the exception of subjective rating in the cystic duct model and procedure time in the colorectal model. CONCLUSION: In this in vitro experimental model, the flexible-tip laparoscopes found to have no advantage over the standard rigid 30 degrees lens laparoscope. These models were validated, as the 0 degrees lens rigid laparoscope was surpassed by the 30 degrees lens rigid laparoscope and the flexible-tip laparoscopes. Both flexible-tip laparoscopes produced similar results and excellent image quality, but some experience is required before their smooth application can be achieved.

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

Modelling and evaluation of surgical performance using hidden Markov models.

Minimally invasive surgery has become very widespread in the last ten years. Since surgeons experience difficulties in learning and mastering minimally invasive techniques, the development of training methods is of great importance. While the introduction of virtual reality-based simulators has introduced a new paradigm in surgical training, skill evaluation methods are far from being objective. This paper proposes a method for defining a model of surgical expertise and an objective metric to evaluate performance in laparoscopic surgery. Our approach is based on the processing of kinematic data describing movements of surgical instruments. We use hidden Markov model theory to define an expert model that describes expert surgical gesture. The model is trained on kinematic data related to exercises performed on a surgical simulator by experienced surgeons. Subsequently, we use this expert model as a reference model in the definition of an objective metric to evaluate performance of surgeons with different abilities. Preliminary results show that, using different topologies for the expert model, the method can be efficiently used both for the discrimination between experienced and novice surgeons, and for the quantitative assessment of surgical ability.

Computer Simulation↗
PubMed2006

Linking processes and outcomes to improve surgical performance: a new approach to morbidity and mortality peer review.

Peer review of surgical cases resulting in death or potentially avoidable complications is a longstanding tradition, but intensive reviews of individual cases rarely produces tangible improvements in clinical outcomes. The systematic comparison of care received by patients who experienced adverse outcomes to care received by patients who had uneventful surgical courses is a promising alternative to intensive case review. However, the results of these studies may be misleading because physicians often choose interventions based on their perceptions of patients' preoperative risks, and higher adverse outcome rates among patients with higher preoperative risk may distort comparisons of alternative interventions. The creation of a control sample by carefully matching each patient who experienced an adverse outcome to a patient who had a similar preoperative risk but did not experience an adverse outcome can overcome this problem and provide excellent insight into how to improve clinical performance most effectively and efficiently. By using currently available electronic data to compute each patient's risk of an adverse outcome, a series of cases with adverse outcomes can be matched to an equal number of controls. Peer review committees can then direct focused data collection and analyses of potentially critical processes of care to determine which, if any, are associated with significantly poorer clinical results. A simulated scenario is analyzed in detail to illustrate the ability of this technique to correctly determine best practices when other approaches fail to do so.

General Surgery↗
PubMed2000

[Photography methods in general and esthetic surgery: clinical significance and impact on surgical performance].

The authors outline and emphasize the use of Polaroid technique in the surgical practice, either in emergency room (pre-, intra- and postoperative photography) or in plastic-reconstructive surgery, where informed consent is needed on the basis of surgical plan. Polaroid photos are suitable to be enclosed in the patient record as well as in the legal documentation. The Polaroid Macro-5SLR camera is specifically useful in the medical practice to improve the doctor-patient relationship.

General Surgery↗