Publications by authors named "Steven D Schwaitzberg"

76 Publications

The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State.

Ann Surg 2021 09;274(3):e245-e252

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY.

Objective: The aim of this study was to examine real-life patterns of care and patient outcomes associated with robot-assisted cholecystectomy (RAC) in New York State (NYS).

Background: Although robotic assistance may offer some technological advantages, RACs are associated with higher procedural costs and longer operating times compared to traditional laparoscopic cholecystectomies (LCs). Evidence on long-term patient outcomes after RAC from large population-based datasets remains limited and inconsistent.

Methods: Using NYS inpatient and ambulatory surgery data from the Statewide Planning and Research Cooperative System (2009-2017), we conducted bivariate and multivariate analyses to examine patterns of utilization, complications, and secondary procedures following cholecystectomies.

Results: Among 299,306 minimally invasive cholecystectomies performed in NYS between 2009 and 2017, one thousand one hundred eighteen (0.4%) were robot-assisted. Compared to those undergoing LC, RAC patients were older, travelled further for surgery, and were more likely to have public insurance and preoperative comorbidities. RAC versus LC patients were more significantly likely to have conversions to open procedure (4.9% vs 2.8%), bile duct injuries (1.3% vs 0.4%), and major reconstructive interventions (0.6% vs 0.1%), longer median length of stay (3 vs 1 day), readmissions (7.3% vs 4.4%), and higher 12-month post-index surgery hospital charges (P < 0.01 for all estimates). Other postoperative complications decreased over time for LC but remained unchanged for RAC patients.

Conclusions: Patients receiving RAC in NYS experienced higher rates of complications compared to LC patients. Addressing patient-, surgeon-, and system-level factors associated with intra/postoperative complications and applying recently promulgated safe cholecystectomy strategies coupled with advanced imaging modalities like fluorescence cholangiography to RAC may improve patient outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004932DOI Listing
September 2021

Can Platelet Leukocyte Ratio Improve the American College of Surgeons Surgical Risk Calculator for Patients with Surgically Resected Colorectal Cancer?

J Gastrointest Surg 2021 08 2;25(8):2110-2113. Epub 2021 Feb 2.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-021-04938-xDOI Listing
August 2021

Dissecting a department of surgery: Exploring organizational culture and competency expectations.

Am J Surg 2021 02 24;221(2):298-302. Epub 2020 Oct 24.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.

Introduction: In order to recruit high-potential trainees, surgery residency and fellowship programs must first understand what competencies and attributes are required for success in their respective programs. This study performed a systematic analysis to define organizational culture and competency expectations across training programs within one academic surgery department.

Methods: Subject matter experts rated the importance and frequency of 22 competencies and completed a 44-item organizational culture inventory along 1 to 5 Likert-type scales.

Results: Importance and frequency attributions of competencies varied significantly among programs (p < .05 by ANOVA), but there was substantial agreement on organizational culture; self-directed (x̄ = 3.8), perfectionist (x̄ = 3.7) and social (x̄ = 3.7) attributes were most representative of the program, while oppositional (x̄ = 1.8), competitive (x̄ = 2.5) and hierarchical (x̄ = 2.7) characteristics were least representative.

Conclusions: Residency and fellowship programs within the same department have shared perceptions of the culture and values of their institution, but seek different competencies among entering trainees.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.10.011DOI Listing
February 2021

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations.

Surg Endosc 2021 Oct 13;35(10):5816-5826. Epub 2020 Oct 13.

Department of Surgery, University at Buffalo, State University of New York Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.

Introduction: The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills.

Methods And Procedures: Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups.

Results: Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups.

Conclusions: Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-08067-5DOI Listing
October 2021

Failure to Rescue from Surgical Complications After Trans-thoracic and Trans-hiatal Esophageal Resection: an ACS-NSQIP Study.

J Gastrointest Surg 2021 02 18;25(2):536-538. Epub 2020 Sep 18.

Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-020-04797-yDOI Listing
February 2021

Do We "Do No Harm" in the Management of Acute Cholecystitis in COVID-19 Patients?

Am Surg 2020 07 15;86(7):748-750. Epub 2020 Jul 15.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003134820939881DOI Listing
July 2020

Characterizing the learning curve of a virtual intracorporeal suturing simulator VBLaST-SS©.

Surg Endosc 2020 07 3;34(7):3135-3144. Epub 2019 Sep 3.

UB RIS²E², Department of Surgery, University at Buffalo, Buffalo, NY, USA.

Background: The virtual basic laparoscopic skill trainer suturing simulator (VBLaST-SS©) was developed to simulate the intracorporeal suturing task in the FLS program. The purpose of this study was to evaluate the training effectiveness and participants' learning curves on the VBLaST-SS© and to assess whether the skills were retained after 2 weeks without training.

Methods: Fourteen medical students participated in the study. Participants were randomly assigned to two training groups (7 per group): VBLaST-SS© or FLS, based on the modality of training. Participants practiced on their assigned system for one session (30 min or up to ten repetitions) a day, 5 days a week for three consecutive weeks. Their baseline, post-test, and retention (after 2 weeks) performance were also analyzed. Participants' performance scores were calculated based on the original FLS scoring system. The cumulative summation (CUSUM) method was used to evaluate learning. Two-way mixed factorial ANOVA was used to compare the effects of group, time point (baseline, post-test, and retention), and their interaction on performance.

Results: Six out of seven participants in each group reached the predefined proficiency level after 7 days of training. Participants' performance improved significantly (p < 0.001) after training within their assigned group. The CUSUM learning curve shows that one participant in each group achieved 5% failure rate by the end of the training period. Twelve out of fourteen participants' CUSUM curves showed a negative trend toward achieving the 5% failure rate after further training.

Conclusion: The VBLaST-SS© is effective in training laparoscopic suturing skill. Participants' performance of intracorporeal suturing was significantly improved after training on both systems and was retained after 2 weeks of no training.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-019-07081-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7051880PMC
July 2020

Debunking Myths About the Purpose and Intentions of Fundamentals of Laparoscopic Surgery Testing.

JAMA Surg 2019 05;154(5):468

Department of Surgery, University at Buffalo, Buffalo, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2018.5584DOI Listing
May 2019

Correction to: Validation of a virtual intracorporeal suturing simulator.

Surg Endosc 2019 Aug;33(8):2473-2474

Department of Surgery, University at Buffalo, Buffalo, NY, USA.

The surname of Sreekanth Arikatla incorrectly appeared as Sreekanth Artikala.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-018-06615-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828503PMC
August 2019

Impact of Trauma Hospital Ransomware Attack on Surgical Residency Training.

J Surg Res 2018 12 19;232:389-397. Epub 2018 Jul 19.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York. Electronic address:

Background: A recent ransomware attack led to the shutdown of the electronic health information system (HIS) at our trauma center for 2 mo. We investigated its impact on residency training during the downtime.

Material And Methods: General and orthopedic surgical residents who rotated at the hospital were invited to participate in a survey regarding their patient care and residency training experiences during the downtime. Attending surgeons from both the specialties were invited to participate in a semistructured interview regarding their attitude toward residency training during the downtime.

Results: Twenty-nine residents responded to the survey with a response rate of 78.4%. Residents acknowledged significant increases in face-to-face communication and decreases in use of online educational resources during the downtime (P < 0.01). Residents were significantly stressed by the dearth of online resources (P < 0.0001) and by paper-based orders and outpatient clinic (P < 0.05). A multivariate analysis demonstrated an inverse relationship between postgraduate year and stress from paper orders (P = 0.003). Attending surgeon's interviews revealed that they recognized residents' unpreparedness and strove harder to teach more effectively.

Conclusions: Our study demonstrated that an unexpected shutdown of the hospital HIS imposed significant stress upon surgical residents providing trauma patient care and made attending surgeons take greater efforts to be more effective teachers. Residents who are digital natives lack adaptability to handle a paper-based workflow. With cyber security threats increasing in health care, preparedness should be included in the graduate medical education curriculum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.06.072DOI Listing
December 2018

Objective assessment of surgical skill transfer using non-invasive brain imaging.

Surg Endosc 2019 08 17;33(8):2485-2494. Epub 2018 Oct 17.

Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA.

Background: Physical and virtual surgical simulators are increasingly being used in training technical surgical skills. However, metrics such as completion time or subjective performance checklists often show poor correlation to transfer of skills into clinical settings. We hypothesize that non-invasive brain imaging can objectively differentiate and classify surgical skill transfer, with higher accuracy than established metrics, for subjects based on motor skill levels.

Study Design: 18 medical students at University at Buffalo were randomly assigned into control, physical surgical trainer, or virtual trainer groups. Training groups practiced a surgical technical task on respective simulators for 12 consecutive days. To measure skill transfer post-training, all subjects performed the technical task in an ex-vivo environment. Cortical activation was measured using functional near-infrared spectroscopy (fNIRS) in the prefrontal cortex, primary motor cortex, and supplementary motor area, due to their direct impact on motor skill learning.

Results: Classification between simulator trained and untrained subjects based on traditional metrics is poor, where misclassification errors range from 20 to 41%. Conversely, fNIRS metrics can successfully classify physical or virtual trained subjects from untrained subjects with misclassification errors of 2.2% and 8.9%, respectively. More importantly, untrained subjects are successfully classified from physical or virtual simulator trained subjects with misclassification errors of 2.7% and 9.1%, respectively.

Conclusion: fNIRS metrics are significantly more accurate than current established metrics in classifying different levels of surgical motor skill transfer. Our approach brings robustness, objectivity, and accuracy in validating the effectiveness of future surgical trainers in translating surgical skills to clinically relevant environments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-018-6535-zDOI Listing
August 2019

Validation of a virtual intracorporeal suturing simulator.

Surg Endosc 2019 08 17;33(8):2468-2472. Epub 2018 Oct 17.

Department of Surgery, University at Buffalo, Buffalo, NY, USA.

Background: Intracorporeal suturing is one of the most important and difficult procedures in laparoscopic surgery. Practicing on a FLS trainer box is effective but requires large number of consumables, and the scoring is somewhat subjective and not immediate. A virtualbasic laparoscopic skill trainer (VBLaST©) was developed to simulate the five tasks of the FLS Trainer Box. The purpose of this study is to evaluate the face and content validity of the VBLaST suturing simulator (VBLaST-SS©).

Methods: Twenty-five medical students and residents completed an evaluation of the simulator. The participants were asked to perform the standard intracorporeal suturing task on both VBLaST-SS© and the traditional FLS box trainer. The performance scores on each system were calculated based on time (s), deviations to the black dots (mm), and incision gap (mm). The participants were then asked to finish a 13-item questionnaire with ratings from 1 (not realistic/useful) to 5 (very realistic/useful) regarding the face validity of the simulator. A Wilcoxon signed rank test was performed to identify differences in performance on the VBLaST-SS© compared to that of the traditional FLS box trainer.

Results: Three questions from the face validity questionnaire were excluded due to lack of response. Ratings to 8 of the remaining 10 questions (80%) averaged above 3.0 out of 5. Average intracorporeal suturing completion time on the VBLaST-SS© was 421 (SD = 168 s) seconds compared to 406 (175 s) seconds on the box trainer (p = 0.620). There was a significant difference between systems for the incision gap (p = 0.048). Deviation in needle insertion from the black dot was smaller for the box trainer than the virtual simulator (1.68 vs. 7.12, p < 0.001).

Conclusion: Participants showed comparable performance on the VBLaST-SS© and traditional box trainer. Overall, the VBLaST-SS© system showed face validity and has the potential to support training for the suturing skills.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-018-6531-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470044PMC
August 2019

Assessing bimanual motor skills with optical neuroimaging.

Sci Adv 2018 10 3;4(10):eaat3807. Epub 2018 Oct 3.

Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA.

Measuring motor skill proficiency is critical for the certification of highly skilled individuals in numerous fields. However, conventional measures use subjective metrics that often cannot distinguish between expertise levels. We present an advanced optical neuroimaging methodology that can objectively and successfully classify subjects with different expertise levels associated with bimanual motor dexterity. The methodology was tested by assessing laparoscopic surgery skills within the framework of the fundamentals of a laparoscopic surgery program, which is a prerequisite for certification in general surgery. We demonstrate that optical-based metrics outperformed current metrics for surgical certification in classifying subjects with varying surgical expertise. Moreover, we report that optical neuroimaging allows for the successful classification of subjects during the acquisition of these skills.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1126/sciadv.aat3807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170034PMC
October 2018

A preclinical animal study of a novel, simple, and secure duct and vessel occluder for laparoscopic surgery.

Surg Endosc 2018 07 16;32(7):3311-3320. Epub 2018 Jan 16.

Jacobs School of Medicine, University at Buffalo, Buffalo, NY, USA.

Background: Secure occlusion of large blood vessels and ductal structures is critical to all surgeries and remains a challenge in many minimally invasive procedures. This study compares in vivo use of the Amsel Occluder (AO) for secure laparoscopic blood vessel and duct closure, with one of the many commercially available hemoclips (Ligaclip®), in the porcine model.

Methods: Laparoscopic closure of vessels and ducts was performed on 12 swine to compare the ease of use, safety and efficacy of the AO with a hemoclip, as well as the tissue response at > 30 days (10 swine). All vessels and ducts were occluded and then transected between the occluding clips. Any bleeding or leakage was noted. In the chronic study, confirmation of satisfactory vessel occlusion post nephrectomy was determined by laparotomy as well as by contrast angiography and venography. The tissue response and healing was evaluated by a histopathological study for the effects of any biological incompatibilities.

Results: In the acute laparoscopic study, a total of 24 occlusions between 2 and 10 mm were performed with the AO (n = 19) and hemoclip (n = 5). In the chronic study, 5 nephrectomies (AO n = 3, hemoclip N = 2) and 5 cholecystectomies (AO n = 3, hemoclip n = 2) were performed with survival ranging from 42 to 72 days. One pig who sustained a splenic injury at trocar insertion and suffered a delayed ruptured spleen with massive hemorrhage on postoperative day 22. Unlike occlusion with the AO, multiple hemoclips were used for each vessel occlusion. Histopathological examination showed no difference in the tissue response and healing of the AO and hemoclip.

Conclusions: The Amsel Vessel occluder delivered laparoscopically provides an occlusion similar to a hand-sewn transfixion suture, is simple to use, and creates an occlusion which is not only more secure, but also as safe with respect to the health of the surrounding tissues, as that of the widely used hemoclip (Ligaclip®).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-018-6052-0DOI Listing
July 2018

The NOVEL trial: natural orifice versus laparoscopic cholecystectomy-a prospective, randomized evaluation.

Surg Endosc 2018 05 7;32(5):2505-2516. Epub 2017 Dec 7.

Gastroenterology Division, Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA, 19104, USA.

Introduction: The evolution of Natural Orifice Translumenal Endoscopic Surgery (NOTES) represents a case study in surgical procedural evolution. Beginning in 2004 with preclinical feasibility studies, and followed by the creation of the NOSCAR collaboration between The Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Gastrointestinal Endoscopy, procedural development followed a stepwise incremental pathway. The work of this consortium has included white paper analyses, obtaining outside independent funding for basic science and procedural development, and, ultimately, the initiation of a prospective randomized clinical trial comparing NOTES cholecystectomy as an alternative procedure to laparoscopic cholecystectomy.

Methods: Ninety patients were randomized into a randomized clinical trial with the primary objective of demonstrating non-inferiority of the transvaginal and transgastric arms to the laparoscopic arm. In the original trial design, there were both transgastric and transvaginal groups to be compared to the laparoscopic control group. However, after enrollment and randomization of 6 laparoscopic controls and 4 transgastric cases into the transgastric group, this arm was ultimately deemed not practical due to lagging enrollment, and the arm was closed. Three transgastric via the transgastric approach were performed in total with 9 laparoscopic control cases enrolled through the TG arm. Overall a total of 41 transvaginal and their 39 laparoscopic cholecystectomy controls were randomized into the study with 37 transvaginal and 33 laparoscopic cholecystectomies being ultimately performed. Overall total operating time was statistically longer in the NOTES group: 96.9 (64.97) minutes versus 52.1 (19.91) minutes.

Results: There were no major adverse events such as common bile duct injury or return to the operating room for hemorrhage. Intraoperative blood loss, length of stay, and total medication given in the PACU were not statistically different. There were no conversions in the NOTES group to a laparoscopic or open procedure, nor were there any injuries, bile leaks, hemorrhagic complications, wound infections, or wound dehiscence in either group. There were no readmissions. Visual Analogue Scale (VAS) pain scores were 3.4 (CI 2.82) in the laparoscopic group and 2.9 (CI 1.96) in the transvaginal group (p = 0.41). The clinical assessment on cosmesis scores was not statistically different when recorded by clinical observers for most characteristics measured when the transvaginal group was compared to the laparoscopic group. Taken as a whole, the results slightly favor the transvaginal group. SF-12 scores were not statistically different at all postoperative time points except for the SF-12 mental component which was superior in the transvaginal group at all time points (p < 0.05).

Conclusion: The safety profile for transvaginal cholecystectomy demonstrates that this approach is safe and produces at least non-inferior clinical results with superior cosmesis, with a transient reduction in discomfort. The transvaginal approach to cholecystectomy should no longer be considered experimental. As a model for intersociety collaboration, the study demonstrated the ultimate feasibility and success of partnership as a model for basic research, procedural development, fundraising, and clinical trial execution for novel interventional concepts, regardless of physician board certification.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-017-5955-5DOI Listing
May 2018

Trends in the Fundamentals of Laparoscopic Surgery® (FLS) certification exam over the past 9 years.

Surg Endosc 2018 04 24;32(4):2101-2105. Epub 2017 Oct 24.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.

Background: The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee.

Methods: A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate.

Results: A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year-PGY1-2), 84% senior (PGY3-5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2-2.8) times higher than that of a PGY1-2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach's alpha dropped to between 0.65 and 0.71, depending on the task being removed.

Conclusion: The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-017-5907-0DOI Listing
April 2018

Validation of the VBLaST pattern cutting task: a learning curve study.

Surg Endosc 2018 04 19;32(4):1990-2002. Epub 2017 Oct 19.

Wright State University, 207 Russ Engineering Center, 3640 Colonel Glenn Hwy, Dayton, OH, 45435, USA.

Background: Mastery of laparoscopic skills is essential in surgical practice and requires considerable time and effort to achieve. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PC) is a virtual simulator that was developed as a computerized version of the pattern cutting (PC) task in the Fundamentals of Laparoscopic Surgery (FLS) system. To establish convergent validity for the VBLaST-PC, we assessed trainees' learning curves using the cumulative summation (CUSUM) method and compared them with those on the FLS.

Methods: Twenty-four medical students were randomly assigned to an FLS training group, a VBLaST training group, or a control group. Fifteen training sessions, 30 min in duration per session per day, were conducted over 3 weeks. All subjects completed pretest, posttest, and retention test (2 weeks after posttest) on both the FLS and VBLaST simulators. Performance data, including time, error, FLS score, learning rate, learning plateau, and CUSUM score, were analyzed.

Results: The learning curve for all trained subjects demonstrated increasing performance and a performance plateau. CUSUM analyses showed that five of the seven subjects reached the intermediate proficiency level but none reached the expert proficiency level after 150 practice trials. Performance was significantly improved after simulation training, but only in the assigned simulator. No significant decay of skills after 2 weeks of disuse was observed. Control subjects did not show any learning on the FLS simulator, but improved continually in the VBLaST simulator.

Conclusions: Although VBLaST- and FLS-trained subjects demonstrated similar learning rates and plateaus, the majority of subjects required more than 150 trials to achieve proficiency. Trained subjects demonstrated improved performance in only the assigned simulator, indicating specificity of training. The virtual simulator may provide better opportunities for learning, especially with limited training exposure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-017-5895-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845471PMC
April 2018

Fundamental Use of Surgical Energy (FUSE): An Essential Educational Program for Operating Room Safety.

Perm J 2017 ;21:16-050

Oncologic Surgeon at the Walnut Creek Medical Center, Interregional NSQIP Physician Lead for The Permanente Federation, and Associate Professor of Surgery at the University of San Francisco-East Bay in CA.

Operating room (OR) safety has become a major concern in patient safety since the 1990s. Improvement of team communication and behavior is a popular target for safety programming at the institutional level. Despite these efforts, essential safety gaps remain in the OR and procedure rooms. A prime example is the use of energy-based devices in ORs and procedural areas. The lack of fundamental understanding of energy device function, design, and application contributes to avoidable injury and harm at a rate of approximately 1 to 2 per 1000 patients in the US. Hundreds of OR fires occur each year in the US, some causing severe injury and even death. Most of these fires are associated with the use of energy-based surgical devices.In response to this safety issue, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamental Use of Surgical Energy (FUSE) program. This program includes a standardized curriculum targeted to surgeons, other physicians, and allied health care professionals and a psychometrically designed and validated certification test. A successful FUSE certification documents acquisition of the basic knowledge needed to safely use energy-based devices in the OR. By design FUSE fills a void in the curriculum and competency assessment for surgeons and other procedural specialists in the use of energy-based devices in patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7812/TPP/16-050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5283782PMC
September 2017

Use of robots in outpatient operations is a costly proposition.

Surgery 2017 03 6;161(3):641. Epub 2017 Jan 6.

Department of Surgery, Jacobs School of Medicine, University of Buffalo, The State University of New York, Buffalo, NY. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2016.11.005DOI Listing
March 2017

OR fire virtual training simulator: design and face validity.

Surg Endosc 2017 09 30;31(9):3527-3533. Epub 2016 Dec 30.

Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, NY, USA.

Background: The Virtual Electrosurgical Skill Trainer is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist, and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head-mounted display, participants must correctly identify the "fire triangle" elements and then successfully contain an OR fire. Within these virtual reality scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons conference.

Methods: Forty-nine subjects with varying experience participated in this Institutional Review Board-approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator.

Results: On a 5-point scale, 12 of 13 questions were rated at a mean of 3 or greater (92%). Five questions were rated above 4 (38%), particularly those focusing on the simulator effectiveness and its usefulness in OR fire safety training. A total of 33 of the 49 participants (67%) chose the virtual OR fire trainer over the traditional training methods such as a textbook or an animal model.

Conclusions: Training for OR fire emergencies in fully immersive VR environments, such as the VEST trainer, may be the ideal training modality. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-016-5379-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232853PMC
September 2017

Leadership development in a professional medical society using 360-degree survey feedback to assess emotional intelligence.

Surg Endosc 2017 09 30;31(9):3565-3573. Epub 2016 Dec 30.

PULSE 360/Physicians Development Program, 2000 S Dixie Hwy. Suite 103, Miami, FL, 33133, USA.

Background: The current research evaluated the potential utility of a 360-degree survey feedback program for measuring leadership quality in potential committee leaders of a professional medical association (PMA). Emotional intelligence as measured by the extent to which self-other agreement existed in the 360-degree survey ratings was explored as a key predictor of leadership quality in the potential leaders.

Study Design: A non-experimental correlational survey design was implemented to assess the variation in leadership quality scores across the sample of potential leaders. A total of 63 of 86 (76%) of those invited to participate did so. All potential leaders received feedback from PMA Leadership, PMA Colleagues, and PMA Staff and were asked to complete self-ratings regarding their behavior.

Results: Analyses of variance revealed a consistent pattern of results as Under-Estimators and Accurate Estimators-Favorable were rated significantly higher than Over-Estimators in several leadership behaviors.

Conclusions: Emotional intelligence as conceptualized in this study was positively related to overall performance ratings of potential leaders. The ever-increasing roles and potential responsibilities for PMAs suggest that these organizations should consider multisource performance reviews as these potential future PMA executives rise through their organizations to assume leadership positions with profound potential impact on healthcare. The current findings support the notion that potential leaders who demonstrated a humble pattern or an accurate pattern of self-rating scored significantly higher in their leadership, teamwork, and interpersonal/communication skills than those with an aggrandizing self-rating.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-016-5386-8DOI Listing
September 2017

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer.

Int J Hum Comput Stud 2016 Dec 9;96:22-37. Epub 2016 Jul 9.

Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, USA.

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijhcs.2016.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214218PMC
December 2016

Does Wearable Medical Technology With Video Recording Capability Add Value to On-Call Surgical Evaluations?

Surg Innov 2016 Oct 22;23(5):498-504. Epub 2016 Jun 22.

Harvard Medical School, Boston, MA, USA Cambridge Health Alliance, Cambridge, MA, USA

Background Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol-which avoids transmission issues associated with real-time applications-for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass' HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1553350616656278DOI Listing
October 2016

Patient comorbidities increase postoperative resource utilization after laparoscopic and open cholecystectomy.

Surg Endosc 2016 06 1;30(6):2217-30. Epub 2015 Oct 1.

University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA.

Background: An understanding of the relationship between patient factors and healthcare resource utilization represents a major point of interest for optimizing clinical care and overall net savings, yet maintaining financial margins for provider revenues. This study aims to review resource utilization after cholecystectomy in order to characterize patient factors associated with increased postoperative ED visits and 30-day readmissions.

Methods: A total of 53,632 open and laparoscopic cholecystectomies were reviewed from July 2009 to December 2010 in a large private payer claims database. ICD-9 and CPT codes were available for each event, as well as basic demographics. Data regarding 30-day postoperative resource utilization metrics (emergency department visits and inpatient hospitalizations) were analyzed and stratified by key patient comorbidities. Differences between subgroups were evaluated with univariate and multivariable methods.

Results: Of the 53,632 patients studied, 71.2 % (38,171) were female and 28.8 % (15,461) male. Resource utilization within 30 days of surgery included: 6.6 % (3538) of patients with an ED visit and 7.7 % (4103) with an inpatient hospitalization. The most common comorbidities in the study population were: hypertension, hyperlipidemia, GERD/hiatal hernia, and diabetes mellitus. Patients with heart failure, cirrhosis, and a history of MI or acute ischemic heart disease all had a significant association with postoperative ED visit and the highest likelihood of inpatient hospitalization. Angina, diabetes, and hypertension similarly increased both ED utilization and inpatient readmissions to a lesser but still significant extent. Although patients with GERD/hiatal hernia and sleep apnea had a significant association with ED use, they did not have an increased likelihood of readmission.

Conclusions: Patient comorbidity indexing plays a major role in clinical risk stratification and resource utilization for cholecystectomy. These factors should be considered in bundled reimbursement packages and in the creation of preventive postoperative ambulatory strategies given their role in determining potential resource utilization in the postoperative setting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-015-4481-6DOI Listing
June 2016

A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training.

Surg Endosc 2016 05 21;30(5):1713-24. Epub 2015 Jul 21.

Department of Surgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA.

Background: Distractions during surgical procedures have been linked to medical error and team inefficiency. This systematic review identifies the most common and most significant forms of distraction in order to devise guidelines for mitigating the effects of distractions in the OR.

Methods: In January 2015, a PubMed and Google Scholar search yielded 963 articles, of which 17 (2 %) either directly observed the occurrence of distractions in operating rooms or conducted a laboratory experiment to determine the effect of distraction on surgical performance.

Results: Observational studies indicated that movement and case-irrelevant conversation were the most frequently occurring distractions, but equipment and procedural distractions were the most severe. Laboratory studies indicated that (1) auditory and mental distractions can significantly impact surgical performance, but visual distractions do not incur the same level of effects; (2) task difficulty has an interaction effect with distractions; and (3) inexperienced subjects reduce their speed when faced with distractions, while experienced subjects did not.

Conclusion: This systematic review suggests that operating room protocols should ensure that distractions from intermittent auditory and mental distractions are significantly reduced. In addition, surgical residents would benefit from training for intermittent auditory and mental distractions in order to develop automaticity and high skill performance during distractions, particularly during more difficult surgical tasks. It is unclear as to whether training should be done in the presence of distractions or distractions should only be used for post-training testing of levels of automaticity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-015-4443-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5663645PMC
May 2016

Long-term knowledge retention following simulation-based training for electrosurgical safety: 1-year follow-up of a randomized controlled trial.

Surg Endosc 2016 Mar 3;30(3):1156-63. Epub 2015 Jul 3.

Department of Surgery, McGill University, Montreal, QC, H3G 1A4, Canada.

Background: Despite the value of simulation for surgical training, it is unclear whether acquired competencies persist long term. A prior randomized trial showed that structured simulation improves knowledge of the safe use of electrosurgery (ES) amongst trainees up to 3 months after the curriculum (Madani et al. in Surg Endosc 28(10):2772-2782, 2014). We now analyse long-term knowledge retention. This study estimates the effects of a structured simulation-based curriculum to teach the safe use of ES on knowledge after 1 year.

Methods: Trainees previously participated in a 1-h didactic ES course, followed by randomization into one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Knowledge of pre- and post-curriculum (immediate, 3 months and 1 year) and knowledge of ES safety were assessed using different multiple-choice examinations. Data are expressed as median (interquartile range), *p < 0.05.

Results: Fifty-nine trainees participated (30 control group; 29 Sim group). Despite equal baseline examination scores, Sim group demonstrated higher scores compared to control immediately (89% [83; 94] vs. 83% [71; 86]*), 3 months (77% [69; 90] vs. 60% [51; 80]*) and 1 year after curriculum (70% [61; 74] vs. 60% [31; 71]*). One-year score remained significantly greater compared to baseline in the Sim group (70% [61; 74] vs. 49% [43; 57]*), but was similar to baseline in the control group (60% [31; 71] vs. 45% [34; 52]).

Conclusions: After ES simulation training, retention of competencies persists longer when the hands-on component is designed to reinforce specific learning objectives in a structured curriculum. Despite routine clinical use of ES devices, knowledge degrades overtime, suggesting the need for ongoing formal educational activities to reinforce curricular objectives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-015-4320-9DOI Listing
March 2016

Fundamental Use of Surgical Energy (FUSE): Closing a Gap in Medical Education.

Ann Surg 2015 Jul;262(1):20-2

*Department of General Surgery, Kaiser Permanente Medical Center, Walnut Creek, CA †Department of Surgery, University of Colorado School of Medicine, Aurora, CO ‡Department of Surgery, McGill University, Montreal, Quebec, Canada §Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada ¶Department of Surgery, Section of Minimally Invasive Surgery, Washington University Institute for Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, MO ‖Department of Anesthesia, Harvard Medical School, Boston, MA **Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA ††Departments of Anesthesiology and Perioperative Medicine and Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX ‡‡Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA §§Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA ¶¶SAGES, Los Angeles, CA ‖‖Department of Surgery, Cambridge Health Alliance, Cambridge, MA ***Department of Surgery, Harvard Medical School, CHA Cambridge Hospital Campus, Cambridge, MA; and ‡‡‡Beth Israel Deaconess Medical Center, Boston, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000001256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484398PMC
July 2015

The successful use of dronabinol for failure to thrive secondary to intestinal dysmotility.

Int J Surg Case Rep 2015 5;11:121-123. Epub 2015 May 5.

Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States.

Introduction: Symptoms of severe intestinal dysmotility decrease patients' quality of life and may prevent them from sustaining adequate oral intake. Dronabinol is a synthetic cannabinoid that is labeled for use in AIDS-related anorexia and chemotherapy-associated nausea and vomiting that has additional efficacy in patients with other etiologies of nausea, vomiting, and anorexia.

Presentation Of Case: We present a 58-year-old female with a history of nausea, vomiting, abdominal pain, and inability to maintain oral intake after multiple laparotomies for ectopic pregnancy, recurrent caecal volvulus, and cholecystitis. After eight years of unsuccessful trials of medicines, dietary modifications, and a partial colectomy, she began a trial of dronabinol, which caused almost complete remission of her symptoms. When this medication was discontinued by her payer, she was unable to maintain oral intake and therefore, was admitted to the hospital for fluid resuscitation and resumption of dronabinol.

Discussion: The use of dronabinol in this patient with severe intestinal dysmotility allowed her to maintain her nutritional status orally and obviated the need for enteral or parenteral feeding. Unfortunately, it was not covered by her insurance company for this indication.

Conclusion: Dronabinol has the potential to improve quality of life for patients beyond those undergoing chemotherapy or suffering from AIDS. Lack of access to this medicine for patients with intestinal dysmotility after all other modalities have been tried can lead to morbid and expensive complications, such as inpatient admission and surgery for enteral access.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijscr.2015.04.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446691PMC
May 2015

Identifying Opportunities for Virtual Reality Simulation in Surgical Education: A Review of the Proceedings from the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) Conference: VR Surgery.

Surg Innov 2015 Oct 29;22(5):514-21. Epub 2015 Apr 29.

Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Objectives: To conduct a review of the state of virtual reality (VR) simulation technology, to identify areas of surgical education that have the greatest potential to benefit from it, and to identify challenges to implementation.

Background Data: Simulation is an increasingly important part of surgical training. VR is a developing platform for using simulation to teach technical skills, behavioral skills, and entire procedures to trainees and practicing surgeons worldwide. Questions exist regarding the science behind the technology and most effective usage of VR simulation. A symposium was held to address these issues.

Methods: Engineers, educators, and surgeons held a conference in November 2013 both to review the background science behind simulation technology and to create guidelines for its use in teaching and credentialing trainees and surgeons in practice.

Results: Several technologic challenges were identified that must be overcome in order for VR simulation to be useful in surgery. Specific areas of student, resident, and practicing surgeon training and testing that would likely benefit from VR were identified: technical skills, team training and decision-making skills, and patient safety, such as in use of electrosurgical equipment.

Conclusions: VR simulation has the potential to become an essential piece of surgical education curriculum but depends heavily on the establishment of an agreed upon set of goals. Researchers and clinicians must collaborate to allocate funding toward projects that help achieve these goals. The recommendations outlined here should guide further study and implementation of VR simulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1553350615583559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578975PMC
October 2015
-->