- Email: [email protected]
Postoperative video debriefing reduces technical errors in laparoscopic surgery
The American Journal of Surgery 194 (2007) 110 –114
Surgical education
Postoperative video debriefing reduces technical errors in laparoscopic surgery Giselle G. Hamad, M.D., F.A.C.S.a,*, Matthew T. Brown, Ph.D.b, Julio A. Clavijo-Alvarez, M.D., Ph.D.a a
Department of Surgery, University of Pittsburgh, 3380 Boulevard of the Allies, Suite 390, Pittsburgh, PA 15213, USA b The Edge School for Athletes, 700 77 Street, SW, Calgary, Alberta, Canada, T3H 5R1 Manuscript received March 28, 2006; revised manuscript October 3, 2006
Abstract Background: Because of the learning curve required to master laparoscopic procedures, there is a growing concern that patient safety may be compromised due to technical errors by a novice surgeon. We evaluated the effect of videotape debriefing on the performance of a complex laparoscopic procedure. Methods: Twenty-four surgical residents performed a laparoscopic jejunojejunal anastomosis under the supervision of a single laparoscopic surgeon. All procedures were videotaped. Half of the residents underwent video debriefing. Videotapes were analyzed for knot-tying time, anastomotic time, and frequency of minor technical errors and adverse events. The performance of the debriefed group was compared with a non-debriefed group. Results: Knot-tying time, minor errors, and anastomotic time were similar between the debriefed and non-debriefed groups. However, adverse events from technical errors were more frequent in the nondebriefed group (2 ⫽ 7.647, P ⫽ .006). Conclusions: Postoperative video debriefing is an effective educational tool for reducing adverse events during a complex laparoscopic procedure. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Adverse events; Debriefing; Laparoscopic surgery; Patient safety; Skills assessment; Surgical education
Laparoscopic surgery, particularly the laparoscopic Rouxen-Y gastric bypass, continues to endure tremendous scrutiny. The epidemic of morbid obesity has created a seemingly insatiable demand for laparoscopic bariatric surgery. The number of bariatric operations increased nearly 5-fold between 1998 and 2002, with a 44-fold increase in laparoscopic bariatric surgery, compared to a 3-fold increase for open bariatric surgery [1]. Unfortunately, mortalities and morbidities resulting from technical complications have gained public attention [2]. Consequently, the American Society of Bariatric Surgery and the Society of American Gastrointestinal Endoscopic Surgeons responded by creating guidelines for granting privileges in laparoscopic bariatric surgery in 2003 [3,4]. Founded in 2004, the Surgical Review Corporation has established rigorous standards for designating a bariatric surgical practice as an American Society of Bariatric Surgery Center of Excellence. The American College of Surgeons has developed a Bariatric * Corresponding author. 300 Halket St. #5518, Pittsburgh, PA 15213. Tel.: ⫹1-412-641-2080; fax: ⫹1-412-641-7878. E-mail address: [email protected]
Surgery Center Network Accreditation Program, which uses a national database to determine risk-adjusted surgical outcomes in an effort to optimize quality of care. However, despite these recommendations, the optimal method for promoting mastery in minimally invasive surgery remains elusive. There is clearly a need for a tool for assessing performance of complex laparoscopic procedures with the objectives of minimizing technical errors and improving patient safety. This study evaluated an educational intervention designed for this purpose. Debriefing has been demonstrated to optimize learning and outcomes in a variety of performance environments [5–11]. In this study, debriefing was employed as an educational tool for surgical residents learning a complex laparoscopic procedure. We analyzed the effect of postoperative video debriefing on the performance of a laparoscopic jejunojejunostomy. Methods Surgical technique Twelve third-year general surgical residents with no previous exposure to laparoscopic bariatric surgery performed a laparoscopic jejunojejunostomy during part of a laparo-
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.10.027
G.G. Hamad et al. / The American Journal of Surgery 194 (2007) 110 –114
scopic Roux-en-Y gastric bypass [12] under the direct supervision of a single experienced laparoscopic surgeon. The residents were observed during their minimally invasive surgery rotation in which they undergo one-on-one training with a single attending surgeon, similar to an apprenticeship. During their rotation, all residents performed basic laparoscopic procedures, which did not involve laparoscopic intracorporeal suturing (laparoscopic cholecystectomy, diagnostic laparoscopy, laparoscopic ventral herniorrhaphy, laparoscopic inguinal herniorrhaphy); these constituted less than 10% of their cases on the rotation. The residents did not receive any formal demonstration preoperatively or standardized preoperative instruction but were encouraged to read about the procedure in preparation for the case. After pneumoperitoneum was established, 5 or 6 access ports were inserted (Versaport; Autosuture, Norwalk, CT). With the patient in the supine position, the jejunum and small bowel mesentery were divided 40 cm distal to the ligament of Treitz with an endoscopic linear stapler (Endo GIA plus, Autosuture). A Penrose drain was sutured to the end of the jejunum distal to the small bowel division using a laparoscopic suturing device (Endostitch, Autosuture). A 75-cm Roux limb was measured for a body mass index less than 50 kg/m2 or a 99-cm limb for a body mass index ⱖ50 kg/m2. A 2-0 polyester stay suture was placed to approximate the 2 limbs of intestine, and a side-to-side jejunojejunostomy was created with a linear stapler. The enterotomy for the stapler was closed transversely with a linear stapler. Antiobstruction sutures of 2-0 polyester were placed proximally and distally. The mesenteric defect was closed with continuous 2-0 silk suture. All procedures were directly recorded onto a videocassette from the laparoscopic camera (Stryker, San Jose, CA). Debriefing Six consecutive residents, constituting the first-half of the the Minimally Invasive Surgical residents studied, did not undergo debriefing, which was introduced as a teaching tool after those 6 residents had completed their minimally invasive surgical rotation. The subsequent 6 consecutive residents underwent video debriefing. They reviewed the videotaped procedure with the attending surgeon on the same day in a single debriefing session per case. The attending surgeon and resident appraised the performance aloud, discussing both the successes and errors of the procedure. During the video assessment, the resident was encouraged to ask questions and to identify skills or strategies that could have been improved. A collaborative summary statement by both the attending and resident recapitulated the lessons learned from the observed procedure, and defined goals and interventions to improve the performance of subsequent cases. Video debriefing was performed only after laparoscopic jejunojejunostomy and not for other laparoscopic procedures (eg, cholecystectomy, herniorrhaphy). Video analysis All videos were analyzed for frequency of minor technical errors and adverse events. Minor errors included dropping tissue or suture, inadvertently catching the needle on a
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loop of suture, twisting the suture without completing a knot, and passing the needle inadvertently through adjacent tissue while tying. Examples of adverse events included breaking a suture, creation of an ischemic end of the divided jejunum requiring resection, and tears of intestinal serosa or mesentery requiring repair. The time required to tie 5 intracorporeal knots with a laparoscopic suturing device was measured for every suture. The time required to perform the jejunojejunal anastomosis, excluding the time for the Roux limb measurement, was measured for each case. The mean knot-tying time, mean anastomotic time, and rates of minor errors and adverse events in the debriefed group were compared with those of the non-debriefed group. This study was approved by the Total Quality Council of the University of Pittsburgh Medical Center. Statistical analysis Results are expressed as mean values ⫾ SD. The groups were compared using repeated measures of analysis of variance for the continuous variables. The Tukey-Kramer test for multiple comparisons was used for post hoc comparisons and chi-square analysis was used for the nomimal data. P ⬍ .05 was considered statistically significant. Results There were no conversions to open gastric bypass. The mean number of laparoscopic jejunojejunostomies was 12.7 ⫾ 1.2 in the non-debriefed group and 13.8 ⫾ 1.3 in the debriefed group (P ⫽ .14). The mean knot-tying time decreased by 44% for the non-debriefed group and by 49% for the debriefed group from week 1 to week 4 (Fig. 1). The standard deviation for knot-tying time decreased progressively for both groups, reflecting an improvement in consistency of knot tying. There was a significant difference between weeks 1 and 3 (P ⬍ .05), with a plateau after week 3. However, repeated measures analysis of variance (ANOVA) showed no difference between groups throughout the 4 weeks of evaluation for mean knot-tying time. The rate of minor errors decreased by 59% for the nondebriefed group and by 29% for the debriefed group from week 1 to week 4 (Fig. 2). The standard deviation for minor
Fig. 1. Mean time to tie 5 laparoscopic intracorporeal knots versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .33. *P ⬍ .05 compared to wk 1.
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Fig. 2. Mean number of minor technical errors per case versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .11. *P ⬍ .05 compared to wk 1.
errors decreased from week 1 to week 4. There was a significant difference between weeks 1 and 2 in both groups (P ⬍ .05), with a plateau after week 2. There was no difference between groups throughout the 4 weeks of evaluation for the rate of minor errors per case by repeated measures of ANOVA. The mean time for performance of the jejunojejunostomy decreased by 29% for the non-debriefed group and by 36% for the debriefed group from week 1 to week 4 (Fig. 3). The standard deviation for anastomotic time decreased from week 1 to week 4. There was a significant difference in anastomotic time between weeks 1 and 3 (P ⬍ .05), with a plateau after week 3. Repeated measures ANOVA showed no difference between groups throughout the 4 weeks of evaluation for mean anastomotic time. There was a significantly higher rate of adverse events in the non-debriefed group compared to the debriefed group (26.5% vs 7.3% for debriefed, 2 ⫽ 7.647, P ⫽ .006). Comments Minimally invasive surgical educational methods continue to evolve. Recently, there has been a growing interest in the objective assessment of surgical competency; the Society of American Gastrointestinal and Endoscopic Surgeons developed the Fundamentals of Laparoscopic Surgery program in response to this need [13]. Traditional surgical outcome parameters include morbidity, mortality, duration of hospital stay, estimated blood loss, and operative time. However, for optimal assessment of progress in technical proficiency, metrics must be applied to standardized surgical tasks so that quantitative values can be evaluated [14]. These methods have major implications for credentialing and accreditation for complex laparoscopic procedures. Because of the tremendous patient demand for minimally invasive surgery, particularly laparoscopic bariatric surgery, many surgeons have rapidly embraced this technique, including those with limited formal training in advanced laparoscopy. Unfortunately, significant complication rates have been reported from surgeons early in their learning curve [15]. The learning curve for full competence in this procedure is reported to be approximately 100 cases [16]. Nguyen et al demonstrated that an operative experience of greater
than 75 cases is associated with shorter operative time and hospital stays and fewer major complications [17]. Nevertheless, case volume alone does not corroborate competency. A method for reducing surgical errors and improving proficiency is critically needed. The objective of this study was to demonstrate the efficacy of a strategy to reduce the number of cases required to ascend the lengthy learning curve associated with a complex laparoscopic procedure. The recognition and discussion of errors and adverse events play a vital role in graduate medical education. The morbidity and morbidity conference, a mainstay of surgery residency programs, is founded on the importance of critical feedback and learning from errors [18]. By the same token, using postoperative debriefing, residents would benefit from regularly reviewing and critiquing their own surgical performance, thereby improving their skills with subsequent opportunities. Debriefing has been used as a performance enhancement tool in the fields of law enforcement [5], marketing [7], occupational therapy [8], education [10], psychology [9], and medicine [6,11]. The objective is to ensure that appropriate and complete lessons have been drawn from a performance [19]. The intervention in the current study combined self-observation with instructor feedback, an approach supported by Paul et al [20], who reported that medical students believed that self-observation made them aware of strengths and weaknesses in their clinical skills, and that commentary from peers and instructors further enhanced this development. The details that an individual recalls from an experience may be distorted and incomplete if left to memory, thereby compromising the lessons learned. The practice of actively reviewing a performance with the trainee promotes the acquisition of accurate feedback that will guide the refinement of their skills. Furthermore, debriefing immediately following a performance facilitates learning by enabling the trainee to articulate the teaching points which a mentor can correct and reinforce while the experience is being assimilated [21], instead of relying on an inaccurate memory of a past performance. The role of video in the feedback process is supported by Fireman et al [22], who demonstrated that self-observation promotes the acquisition and transfer of procedural knowledge necessary for problem solving. The authors determined that specific information presented during the video
Fig. 3. Mean time to perform a laparoscopic jejunojejunal anastomosis versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .81. *P ⬍ .05 compared to wk 1.
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presentation was less important than observing the actual prior performance, challenging the traditional stance that an instructor’s verbal feedback alone is adequate. Videotape feedback, including self-observation and feedback from an instructor, has been shown to enhance performance in the fields of education [22], coaching [23], athletics [24,25], and medicine [26]. Video-enhanced feedback has been shown to improve performance of complex manual skills. Hodges et al [27] demonstrated that performers of a bimanual coordination pattern were better able to distinguish between correct and incorrect movement patterns when such feedback was provided. That is, video feedback enhances the discrimination process, the same process that is critical to the refinement of operative skills. Individuals receiving video feedback showed better performance in acquisition and retention than the non-feedback group. Nakada et al found that videotape analysis improved laparoscopic suturing by urologists [28]. High-resolution laparoscopic video imagery provides an accurate illustration of the surgical performance [29]. During debriefing, the attending surgeon can use the video images to support their critique. Furthermore, the trainees are less apt to distort their recollection of their performance; unlike memory, the videotaped events are irrefutable. The standardization of the jejunojejunostomy further promotes the residents’ education; the resident follows discrete, reproducible steps [30]. We did not expect the trends in knot-tying time, time for completing the anastomosis, and minor errors to be similar in both groups. The attending’s intraoperative corrections in the operative theatre and the residents’ independent practice sessions outside of the operating room may explain the parallel trends in skill performance improvement. Intraoperative feedback and independent practice could affect the learning curve for the procedure and could augment the residents’ knowledge of adverse events. Nevertheless, the difference in the rate of adverse events is a significant finding, and carries implications for patient safety and quality improvement. It is plausible that the debriefing discussions were more effective than intraoperative critique in identifying critical maneuvers or strategies that would reduce adverse events in subsequent procedures. In the setting of a technically challenging procedure, debriefing may be a useful tool not only for reinforcing the concurrent intraoperative feedback but also for expanding a resident’s repertoire beyond the straightforward case. Limitations of this study include the small number of subjects, which is limited by the number of surgical residents in the training program and by the lack of randomization. A limiting factor in carrying out a randomized study is that the residents have declined to be randomized because they unanimously wish to undergo the debriefing sessions. Another possible criticism of the study is that the nondebriefed residents were trained prior to the debriefed residents, and that those cases were earlier in the author’s experience. Theoretically, one might infer that a steep learning curve could have contributed to the difference in adverse events. However, when the non-debriefed residents were trained, the attending surgeon had already ascended the learning curve [16] and by that time, had performed
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more than 180 laparoscopic gastric bypasses as an attending. Regardless, it is undeniable that with more cases and more experience, a surgeon has a heightened alertness for avoiding past complications. Debriefing has the potential to improve the efficacy of minimally invasive surgical education. In July 2003, the Accreditation Council for Graduate Medical Education began enforcing a policy limiting the work week for residents to 80 hours [31]. A growing concern among surgeons and surgery residents alike is whether compliance with these policies compromises training and quality of care because of a reduction in the number of operative cases [32,33]. Among surgical residents, the work hour restrictions are perceived to have a negative impact on education and surgical proficiency because the 80-hour restriction limits the quantity of surgical procedures that can be performed. Graduate surgical education is based on repetitive patient encounters, maximizing operative cases, and continuity of care, all of which could be diminished by the duty hour restrictions. The ramifications of the work hour restrictions on patient safety and outcomes remain unclear. Surgical training was originally predicated on the observation of a case in the operating room and subsequent performance of the procedure, hence the popular adage, “Watch one; do one; teach one.” In the era of the 80-hour work week, preoperative preparation and education by surgical residents outside of the operating room have become even more critical for enhancing their technical skills and improving surgical performance. Considering the stakes involved when trainees operate on live patients, it is vital that residents maximize the learning and performance refinement gained from each operation. Given the recent public attention on patient safety and the focus on quality improvement in surgery, there is a critical need for innovative educational methods so that the time spent in the operating room is used optimally and so that quality of care is preserved. Conclusion The current study validates the use of video debriefing as an effective educational tool for reducing adverse events by surgeons learning a complex laparoscopic procedure. This educational strategy has the potential to improve the safety of the laparoscopic gastric bypass, which has a steep learning curve [16,17]. Video debriefing holds promise for enhancing surgical education and improving surgical performance and may play a role in distance surgical education and telementoring [34]. References [1] Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198 –202. [2] Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery. Executive report. Obes Res 2005;13:205–26. [3] Guidelines for institutions granting bariatric privileges utilizing laparoscopic techniques. Los Angeles, CA: Society of American Gastrointestinal and Endoscopic Surgeons. Available at: http://www.sages. org/sagespublication.php?doc⫽31. Accessed March 23, 2006 (last update October 2003).
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[4] Guidelines for granting privileges in bariatric surgery. Gainesville, FL: American Society for Bariatric Surgery. Available at: http:// www.asbs.org/html/about/grantingpriviledges.html. Accessed March 23, 2006 (last update October 2005). [5] Davis J. The emergence of psychologists as human factors and performance consultants to law enforcement. Hum Perform Extreme Environ 1997;2:34 – 6. [6] Finer NN, Rich W. Neonatal resuscitation: toward improved performance. Resuscitation 2002;53:47–51. [7] Jarvis C. Learning (or failing to learn) from experience: the dysfunctional implications of counterfactual thinking in reviewing past events to improve marketing performance. Doctoral Dissertations International 2000;60. [8] MacKenzie L. Briefing and debriefing of student fieldwork experiences: exploring concerns and reflecting on practice. Aust Occup Ther J 2002;49:82–92. [9] Palya W. The debriefing form. Teach Psychol 1978;5:214 – 6. [10] Roth W. Teacher questioning in an open-inquiry learning environment: interactions of context, content, and student responses. J Res Sci Teach 1996;33:709 –36. [11] Schwid HA, Rooke GA, Michalowski P, et al. Screen-based anesthesia simulation with debriefing improves performance in a mannequinbased anesthesia simulator. Teach Learn Med 2001;13:92– 6. [12] Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–529. [13] Swanstrom LL, Fried GM, Hoffman KI, Soper NJ. Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg 2006;202:62– 69. [14] Gallagher AG, Smith CD, Bowers SP, et al. Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures. J Am Coll Surg 2003;197:479 – 488. [15] Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957–961. [16] Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 2003;17:212–215. [17] Nguyen NT, Rivers R, Wolfe BM. Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg 2003;197: 548 –555; discussion 555–547. [18] Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA 2003; 290:2838 –2842.
[19] Baker A, Jensen P, Kolb D. In conversation: Transforming experience into learning. Simulation & Gaming 1997;28:6 –12. [20] Paul S, Dawson KP, Lanphear JH, Cheema MY. Video recording feedback: a feasible and effective approach to teaching history-taking and physical examination skills in undergraduate paediatric medicine. Med Educ 1998;32:332–336. [21] Lederman L. Debriefing: A critical reexamination of the post-experience analytic process with implications for its effective use. Simulations & Games 1984;15:415– 431. [22] Fireman G, Kose G, Solomon M. Self-observing and learning: The effect of watching oneself on problem solving performance. Cognitive Development 2003;18:339 –354. [23] Ormand T, Blann F. Improving coaches’ performances. Applied Research in Coaching and Athletics Annual 1994;66 –78. [24] Darden G. Videotape feedback for student learning and performance: a learning stages approach. J Physical Education, Recreation, & Dance 1999;70:40 – 45. [25] Rikli R, Smith G. Videotape feedback effects on tennis serving form. Perceptual & Motor Skills 1980;50:895–901. [26] Sarla P, Dawson KP, Lamphear JH, Cheema MY. A feasible and effective approach to teaching history-taking and physical examination skills in undergraduate paediatric medicine. Med Educ 1998;32: 332–336. [27] Hodges N, Chua R, Franks I. The role of video in facilitating perception and action of a novel coordination movement. J Motor Behavior 2003;35:247–260. [28] Nakada SY, Hedican SP, Bishoff JT, et al. Expert videotape analysis and critiquing benefit laparoscopic skills training of urologists. JSLS 2004;8:183–186. [29] Joice P, Hanna GB, Cuschieri A. Errors enacted during endoscopic surgery–a human reliability analysis. Appl Ergon 1998;29:409 – 414. [30] Calland JF, Guerlain S, Adams RB, et al. A systems approach to surgical safety. Surg Endosc 2002;16:1005–1014; discussion 1015. [31] Common program requirements for resident duty hours Chicago: Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyHoursCommonPR. pdf. Accessed March 23, 2006 (last update February 2004). [32] Irani JL, Mello MM, Ashley SW, et al. Surgical residents’ perceptions of the effects of the ACGME duty hour requirements 1 year after implementation. Surgery 2005;138:246 –253. [33] Whang EE, Perez A, Ito H, et al. Work hours reform: perceptions and desires of contemporary surgical residents. J Am Coll Surg 2003;197: 624 – 630. [34] Rosser JC, Jr., Herman B, Giammaria LE. Telementoring. Semin Laparosc Surg 2003;10:209 –217.
Surgical education
Postoperative video debriefing reduces technical errors in laparoscopic surgery Giselle G. Hamad, M.D., F.A.C.S.a,*, Matthew T. Brown, Ph.D.b, Julio A. Clavijo-Alvarez, M.D., Ph.D.a a
Department of Surgery, University of Pittsburgh, 3380 Boulevard of the Allies, Suite 390, Pittsburgh, PA 15213, USA b The Edge School for Athletes, 700 77 Street, SW, Calgary, Alberta, Canada, T3H 5R1 Manuscript received March 28, 2006; revised manuscript October 3, 2006
Abstract Background: Because of the learning curve required to master laparoscopic procedures, there is a growing concern that patient safety may be compromised due to technical errors by a novice surgeon. We evaluated the effect of videotape debriefing on the performance of a complex laparoscopic procedure. Methods: Twenty-four surgical residents performed a laparoscopic jejunojejunal anastomosis under the supervision of a single laparoscopic surgeon. All procedures were videotaped. Half of the residents underwent video debriefing. Videotapes were analyzed for knot-tying time, anastomotic time, and frequency of minor technical errors and adverse events. The performance of the debriefed group was compared with a non-debriefed group. Results: Knot-tying time, minor errors, and anastomotic time were similar between the debriefed and non-debriefed groups. However, adverse events from technical errors were more frequent in the nondebriefed group (2 ⫽ 7.647, P ⫽ .006). Conclusions: Postoperative video debriefing is an effective educational tool for reducing adverse events during a complex laparoscopic procedure. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Adverse events; Debriefing; Laparoscopic surgery; Patient safety; Skills assessment; Surgical education
Laparoscopic surgery, particularly the laparoscopic Rouxen-Y gastric bypass, continues to endure tremendous scrutiny. The epidemic of morbid obesity has created a seemingly insatiable demand for laparoscopic bariatric surgery. The number of bariatric operations increased nearly 5-fold between 1998 and 2002, with a 44-fold increase in laparoscopic bariatric surgery, compared to a 3-fold increase for open bariatric surgery [1]. Unfortunately, mortalities and morbidities resulting from technical complications have gained public attention [2]. Consequently, the American Society of Bariatric Surgery and the Society of American Gastrointestinal Endoscopic Surgeons responded by creating guidelines for granting privileges in laparoscopic bariatric surgery in 2003 [3,4]. Founded in 2004, the Surgical Review Corporation has established rigorous standards for designating a bariatric surgical practice as an American Society of Bariatric Surgery Center of Excellence. The American College of Surgeons has developed a Bariatric * Corresponding author. 300 Halket St. #5518, Pittsburgh, PA 15213. Tel.: ⫹1-412-641-2080; fax: ⫹1-412-641-7878. E-mail address: [email protected]
Surgery Center Network Accreditation Program, which uses a national database to determine risk-adjusted surgical outcomes in an effort to optimize quality of care. However, despite these recommendations, the optimal method for promoting mastery in minimally invasive surgery remains elusive. There is clearly a need for a tool for assessing performance of complex laparoscopic procedures with the objectives of minimizing technical errors and improving patient safety. This study evaluated an educational intervention designed for this purpose. Debriefing has been demonstrated to optimize learning and outcomes in a variety of performance environments [5–11]. In this study, debriefing was employed as an educational tool for surgical residents learning a complex laparoscopic procedure. We analyzed the effect of postoperative video debriefing on the performance of a laparoscopic jejunojejunostomy. Methods Surgical technique Twelve third-year general surgical residents with no previous exposure to laparoscopic bariatric surgery performed a laparoscopic jejunojejunostomy during part of a laparo-
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.10.027
G.G. Hamad et al. / The American Journal of Surgery 194 (2007) 110 –114
scopic Roux-en-Y gastric bypass [12] under the direct supervision of a single experienced laparoscopic surgeon. The residents were observed during their minimally invasive surgery rotation in which they undergo one-on-one training with a single attending surgeon, similar to an apprenticeship. During their rotation, all residents performed basic laparoscopic procedures, which did not involve laparoscopic intracorporeal suturing (laparoscopic cholecystectomy, diagnostic laparoscopy, laparoscopic ventral herniorrhaphy, laparoscopic inguinal herniorrhaphy); these constituted less than 10% of their cases on the rotation. The residents did not receive any formal demonstration preoperatively or standardized preoperative instruction but were encouraged to read about the procedure in preparation for the case. After pneumoperitoneum was established, 5 or 6 access ports were inserted (Versaport; Autosuture, Norwalk, CT). With the patient in the supine position, the jejunum and small bowel mesentery were divided 40 cm distal to the ligament of Treitz with an endoscopic linear stapler (Endo GIA plus, Autosuture). A Penrose drain was sutured to the end of the jejunum distal to the small bowel division using a laparoscopic suturing device (Endostitch, Autosuture). A 75-cm Roux limb was measured for a body mass index less than 50 kg/m2 or a 99-cm limb for a body mass index ⱖ50 kg/m2. A 2-0 polyester stay suture was placed to approximate the 2 limbs of intestine, and a side-to-side jejunojejunostomy was created with a linear stapler. The enterotomy for the stapler was closed transversely with a linear stapler. Antiobstruction sutures of 2-0 polyester were placed proximally and distally. The mesenteric defect was closed with continuous 2-0 silk suture. All procedures were directly recorded onto a videocassette from the laparoscopic camera (Stryker, San Jose, CA). Debriefing Six consecutive residents, constituting the first-half of the the Minimally Invasive Surgical residents studied, did not undergo debriefing, which was introduced as a teaching tool after those 6 residents had completed their minimally invasive surgical rotation. The subsequent 6 consecutive residents underwent video debriefing. They reviewed the videotaped procedure with the attending surgeon on the same day in a single debriefing session per case. The attending surgeon and resident appraised the performance aloud, discussing both the successes and errors of the procedure. During the video assessment, the resident was encouraged to ask questions and to identify skills or strategies that could have been improved. A collaborative summary statement by both the attending and resident recapitulated the lessons learned from the observed procedure, and defined goals and interventions to improve the performance of subsequent cases. Video debriefing was performed only after laparoscopic jejunojejunostomy and not for other laparoscopic procedures (eg, cholecystectomy, herniorrhaphy). Video analysis All videos were analyzed for frequency of minor technical errors and adverse events. Minor errors included dropping tissue or suture, inadvertently catching the needle on a
111
loop of suture, twisting the suture without completing a knot, and passing the needle inadvertently through adjacent tissue while tying. Examples of adverse events included breaking a suture, creation of an ischemic end of the divided jejunum requiring resection, and tears of intestinal serosa or mesentery requiring repair. The time required to tie 5 intracorporeal knots with a laparoscopic suturing device was measured for every suture. The time required to perform the jejunojejunal anastomosis, excluding the time for the Roux limb measurement, was measured for each case. The mean knot-tying time, mean anastomotic time, and rates of minor errors and adverse events in the debriefed group were compared with those of the non-debriefed group. This study was approved by the Total Quality Council of the University of Pittsburgh Medical Center. Statistical analysis Results are expressed as mean values ⫾ SD. The groups were compared using repeated measures of analysis of variance for the continuous variables. The Tukey-Kramer test for multiple comparisons was used for post hoc comparisons and chi-square analysis was used for the nomimal data. P ⬍ .05 was considered statistically significant. Results There were no conversions to open gastric bypass. The mean number of laparoscopic jejunojejunostomies was 12.7 ⫾ 1.2 in the non-debriefed group and 13.8 ⫾ 1.3 in the debriefed group (P ⫽ .14). The mean knot-tying time decreased by 44% for the non-debriefed group and by 49% for the debriefed group from week 1 to week 4 (Fig. 1). The standard deviation for knot-tying time decreased progressively for both groups, reflecting an improvement in consistency of knot tying. There was a significant difference between weeks 1 and 3 (P ⬍ .05), with a plateau after week 3. However, repeated measures analysis of variance (ANOVA) showed no difference between groups throughout the 4 weeks of evaluation for mean knot-tying time. The rate of minor errors decreased by 59% for the nondebriefed group and by 29% for the debriefed group from week 1 to week 4 (Fig. 2). The standard deviation for minor
Fig. 1. Mean time to tie 5 laparoscopic intracorporeal knots versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .33. *P ⬍ .05 compared to wk 1.
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Fig. 2. Mean number of minor technical errors per case versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .11. *P ⬍ .05 compared to wk 1.
errors decreased from week 1 to week 4. There was a significant difference between weeks 1 and 2 in both groups (P ⬍ .05), with a plateau after week 2. There was no difference between groups throughout the 4 weeks of evaluation for the rate of minor errors per case by repeated measures of ANOVA. The mean time for performance of the jejunojejunostomy decreased by 29% for the non-debriefed group and by 36% for the debriefed group from week 1 to week 4 (Fig. 3). The standard deviation for anastomotic time decreased from week 1 to week 4. There was a significant difference in anastomotic time between weeks 1 and 3 (P ⬍ .05), with a plateau after week 3. Repeated measures ANOVA showed no difference between groups throughout the 4 weeks of evaluation for mean anastomotic time. There was a significantly higher rate of adverse events in the non-debriefed group compared to the debriefed group (26.5% vs 7.3% for debriefed, 2 ⫽ 7.647, P ⫽ .006). Comments Minimally invasive surgical educational methods continue to evolve. Recently, there has been a growing interest in the objective assessment of surgical competency; the Society of American Gastrointestinal and Endoscopic Surgeons developed the Fundamentals of Laparoscopic Surgery program in response to this need [13]. Traditional surgical outcome parameters include morbidity, mortality, duration of hospital stay, estimated blood loss, and operative time. However, for optimal assessment of progress in technical proficiency, metrics must be applied to standardized surgical tasks so that quantitative values can be evaluated [14]. These methods have major implications for credentialing and accreditation for complex laparoscopic procedures. Because of the tremendous patient demand for minimally invasive surgery, particularly laparoscopic bariatric surgery, many surgeons have rapidly embraced this technique, including those with limited formal training in advanced laparoscopy. Unfortunately, significant complication rates have been reported from surgeons early in their learning curve [15]. The learning curve for full competence in this procedure is reported to be approximately 100 cases [16]. Nguyen et al demonstrated that an operative experience of greater
than 75 cases is associated with shorter operative time and hospital stays and fewer major complications [17]. Nevertheless, case volume alone does not corroborate competency. A method for reducing surgical errors and improving proficiency is critically needed. The objective of this study was to demonstrate the efficacy of a strategy to reduce the number of cases required to ascend the lengthy learning curve associated with a complex laparoscopic procedure. The recognition and discussion of errors and adverse events play a vital role in graduate medical education. The morbidity and morbidity conference, a mainstay of surgery residency programs, is founded on the importance of critical feedback and learning from errors [18]. By the same token, using postoperative debriefing, residents would benefit from regularly reviewing and critiquing their own surgical performance, thereby improving their skills with subsequent opportunities. Debriefing has been used as a performance enhancement tool in the fields of law enforcement [5], marketing [7], occupational therapy [8], education [10], psychology [9], and medicine [6,11]. The objective is to ensure that appropriate and complete lessons have been drawn from a performance [19]. The intervention in the current study combined self-observation with instructor feedback, an approach supported by Paul et al [20], who reported that medical students believed that self-observation made them aware of strengths and weaknesses in their clinical skills, and that commentary from peers and instructors further enhanced this development. The details that an individual recalls from an experience may be distorted and incomplete if left to memory, thereby compromising the lessons learned. The practice of actively reviewing a performance with the trainee promotes the acquisition of accurate feedback that will guide the refinement of their skills. Furthermore, debriefing immediately following a performance facilitates learning by enabling the trainee to articulate the teaching points which a mentor can correct and reinforce while the experience is being assimilated [21], instead of relying on an inaccurate memory of a past performance. The role of video in the feedback process is supported by Fireman et al [22], who demonstrated that self-observation promotes the acquisition and transfer of procedural knowledge necessary for problem solving. The authors determined that specific information presented during the video
Fig. 3. Mean time to perform a laparoscopic jejunojejunal anastomosis versus number of weeks of the rotation. Non-debriefed versus debriefed, P ⫽ .81. *P ⬍ .05 compared to wk 1.
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presentation was less important than observing the actual prior performance, challenging the traditional stance that an instructor’s verbal feedback alone is adequate. Videotape feedback, including self-observation and feedback from an instructor, has been shown to enhance performance in the fields of education [22], coaching [23], athletics [24,25], and medicine [26]. Video-enhanced feedback has been shown to improve performance of complex manual skills. Hodges et al [27] demonstrated that performers of a bimanual coordination pattern were better able to distinguish between correct and incorrect movement patterns when such feedback was provided. That is, video feedback enhances the discrimination process, the same process that is critical to the refinement of operative skills. Individuals receiving video feedback showed better performance in acquisition and retention than the non-feedback group. Nakada et al found that videotape analysis improved laparoscopic suturing by urologists [28]. High-resolution laparoscopic video imagery provides an accurate illustration of the surgical performance [29]. During debriefing, the attending surgeon can use the video images to support their critique. Furthermore, the trainees are less apt to distort their recollection of their performance; unlike memory, the videotaped events are irrefutable. The standardization of the jejunojejunostomy further promotes the residents’ education; the resident follows discrete, reproducible steps [30]. We did not expect the trends in knot-tying time, time for completing the anastomosis, and minor errors to be similar in both groups. The attending’s intraoperative corrections in the operative theatre and the residents’ independent practice sessions outside of the operating room may explain the parallel trends in skill performance improvement. Intraoperative feedback and independent practice could affect the learning curve for the procedure and could augment the residents’ knowledge of adverse events. Nevertheless, the difference in the rate of adverse events is a significant finding, and carries implications for patient safety and quality improvement. It is plausible that the debriefing discussions were more effective than intraoperative critique in identifying critical maneuvers or strategies that would reduce adverse events in subsequent procedures. In the setting of a technically challenging procedure, debriefing may be a useful tool not only for reinforcing the concurrent intraoperative feedback but also for expanding a resident’s repertoire beyond the straightforward case. Limitations of this study include the small number of subjects, which is limited by the number of surgical residents in the training program and by the lack of randomization. A limiting factor in carrying out a randomized study is that the residents have declined to be randomized because they unanimously wish to undergo the debriefing sessions. Another possible criticism of the study is that the nondebriefed residents were trained prior to the debriefed residents, and that those cases were earlier in the author’s experience. Theoretically, one might infer that a steep learning curve could have contributed to the difference in adverse events. However, when the non-debriefed residents were trained, the attending surgeon had already ascended the learning curve [16] and by that time, had performed
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more than 180 laparoscopic gastric bypasses as an attending. Regardless, it is undeniable that with more cases and more experience, a surgeon has a heightened alertness for avoiding past complications. Debriefing has the potential to improve the efficacy of minimally invasive surgical education. In July 2003, the Accreditation Council for Graduate Medical Education began enforcing a policy limiting the work week for residents to 80 hours [31]. A growing concern among surgeons and surgery residents alike is whether compliance with these policies compromises training and quality of care because of a reduction in the number of operative cases [32,33]. Among surgical residents, the work hour restrictions are perceived to have a negative impact on education and surgical proficiency because the 80-hour restriction limits the quantity of surgical procedures that can be performed. Graduate surgical education is based on repetitive patient encounters, maximizing operative cases, and continuity of care, all of which could be diminished by the duty hour restrictions. The ramifications of the work hour restrictions on patient safety and outcomes remain unclear. Surgical training was originally predicated on the observation of a case in the operating room and subsequent performance of the procedure, hence the popular adage, “Watch one; do one; teach one.” In the era of the 80-hour work week, preoperative preparation and education by surgical residents outside of the operating room have become even more critical for enhancing their technical skills and improving surgical performance. Considering the stakes involved when trainees operate on live patients, it is vital that residents maximize the learning and performance refinement gained from each operation. Given the recent public attention on patient safety and the focus on quality improvement in surgery, there is a critical need for innovative educational methods so that the time spent in the operating room is used optimally and so that quality of care is preserved. Conclusion The current study validates the use of video debriefing as an effective educational tool for reducing adverse events by surgeons learning a complex laparoscopic procedure. This educational strategy has the potential to improve the safety of the laparoscopic gastric bypass, which has a steep learning curve [16,17]. Video debriefing holds promise for enhancing surgical education and improving surgical performance and may play a role in distance surgical education and telementoring [34]. References [1] Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198 –202. [2] Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery. Executive report. Obes Res 2005;13:205–26. [3] Guidelines for institutions granting bariatric privileges utilizing laparoscopic techniques. Los Angeles, CA: Society of American Gastrointestinal and Endoscopic Surgeons. Available at: http://www.sages. org/sagespublication.php?doc⫽31. Accessed March 23, 2006 (last update October 2003).
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