2005 SAGES Abstracts

POSTER ABSTRACTS
SAGES 2005
able weightings contributing to score. We feel that the number
and type of errors in laparoscopic training are more significant
than either time or economy. MIST-VR variable weightings
contributing to score should be modified according to training
purposes.
P177–Education/Outcomes
PREVENTING COMMON BILE DUCT INJURIES IN LAPARO-
SCOPIC CHOLECYSTECTOMY - A TEACHING INSTITUTE
EXPERIENCE, Abhay N Dalvi MS, Pinky M Thapar MS, Aparna
A Deshpande MS,Sameer A Rege MS, Seth G S Medical
College & King Edward VII Memorial Hospital
Common bile duct (CBD) injuries after laparoscopic cholecystectomy
(LC) have faulted the learning curve or experienced
surgeons. Conversion rates range from 4.3 to 19%.(1-3)
Teaching institutes are reported to have higher incidence of
complications (0.65% to 0.3%)(4-6). In our Institute, starting the
LC in 1994, we had a policy of converting the LC to open as
soon as the operating surgeon or the supervising surgeon
realized that it could cause CBD injury. A record was kept of all
surgeons in training that varied on time scale. The aim was to
convert before CBD injury. Factors were analyzed as to the
causes of conversion. The results of the study on varying factors
that influenced the reason for conversion are presented.
From 1994 to 1996 while the faculty was under training, we
analyzed the factors responsible for conversion. Nineteen factors
were analyzed and a computer generated multivariate
analysis was done. Of the 276 patients subjected to LC, conversion
was in 22 (7.97%) with CBD injury in 2 (0.72%). Age
greater than 65 years, prior upper abdominal surgery, ERC,
palpable lump, wall thickness more than 4 mm, shrunken GB
were the cause for conversion. From 1997 onwards, we had
trained teachers; and resident doctors under training. Keeping
the same principle of ?convert before CBD injury?, we kept on
performing LC under supervision and being taken over by a
senior as required. We have performed a total of 1260 LC with
a conversion rate of 7.85% (n = 99). While the conversion rate
was comparable, analysis of the cause of conversions was different.
Contracted gall bladder (44.52%), pericholecystic collection
(18.75%), adhesions (13.02%) and anatomical cause
(13.23%) were the cause of conversions. The CBD injury rate in
1260 cases done was 3 (0.23%) comparable to literature.
Literature review suggests that visual perception illusion(7-9)
and adhesions are commonest cause of CBD injuries. A common
aim in a teaching institute can bring down the morbidity
of CBD injury in LC. Constant supervision and vigilance can
stem down the rate of CBD injuries.
1.Sikora WJS 1995
2.Woods Am J Surg 1994
3.Roslyn Ann Surg 1993
4.Fletcher Ann Surg 1994
5.Gouma J Am Coll Surg 1994
6.Woods Surg Endosc 1995
7.Bingener Arch Surg 2003
8.Krahenbuhl WJS 2001
9.Way Ann Surg 2003
P178–Education/Outcomes
OPERATIVE END-PRODUCT QUALITY AND PROCEDURE
EFFECTIVENESS COMPARING ROBOTIC CAMERA HOLDER TO
HUMAN CAMERA HOLDER IN A LAPAROSCOPIC INANIMATE
SIMULATOR, Miro Uchal MD, Chris Haughn MD,Sam Rossi
MD,Yannis Raftopoulos MD,Marc Torpey,Roberto Bergamaschi
PhD, Dept. og Research and Develop., Forde Health System,
Bergen University, Forde, Norway and Minimally Invasive
Surgery Center, Allegheny General Hospital, Pittsburgh, PA
Some reports suggested that robotic camera holders (RCH)
may be superior to a human camera holder (HCH) in terms of
motion efficiency, and rate of surgical error. This study aims to
compare RCH to HCH with regard to operative end-product
quality (OEPQ) and procedure effectiveness (PE) of suturing a
perforated ulcer in a laparoscopic simulator.
This was a prospective randomized crossover trial including
voluntary post-graduate year (PGY) residents. Block randomization
generated RCH - HCH or HCH - RCH sequence allocation.
Tasks were suturing a perforated ulcer in a foam stomach
and intracorporeally tying a surgeon?s knot in a inanimate
physical simulator. The same voice-controlled robot and the
same person operated the camera during all tasks. OEPQ was
measured by accuracy error (AE), tissue damage (TD), sliding
knot (SK) and leak rates. PE was measured by operating time
(OT), non-goal directed actions (NGDA), and dangerous movements
(DM). 44 subjects were needed to declare significant a
1-min difference in operating time at the alpha=0.05 with 90%
power. Data were presented as median (range). McNemar,
Wilcoxon matched pair rank sum, and t-test were used for
binary (SK, leak), ordinal (AE, TD, NGDA, DM), and continuous
variables (OT), respectively. Kendall?s coefficient tau_b was
used for concordance of 2 raters? evaluation to assess interrater
reliability (IRR).
44 subjects performed tasks as allocated. There were 15 PGY1,
8 PGY2, 5 PGY3, 4 PGY4, 6 PGY5, 6 PGY6. All variables were
not significantly different comparing 1st to 2nd task ignoring
camera holder type. There was no evidence of unequal carryover
effect when comparison was stratified by RCH - HCH or
HCH - RCH sequence. Comparing RCH to HCH, leak rates
(15.9% vs 34% p=0.001) and operating time (139 vs 159 p0.80) except for DM (tau_b=0.72, p=0.08).
RCH compared to HCH led to decreased leak rate and operating
time in suturing a perforated ulcer in a simulator.
P179–Education/Outcomes
LARGE-SCALE ASSESSMENT OF LAPAROSCOPIC SKILLS
USING SIMULATION: ANALYSIS FROM THE 2004 SAGES
LEARNING CENTER MIST-VR STUDY, Kent R Van Sickle MD,
Anthony G Gallagher PhD,E. Matt Ritter MD,David A McClusky
MD,Andrew Ledermen MD,Mercedeh Baghai MD,C. Daniel
Smith MD, Emory Endosurgery Unit, Emory University School
of Medicine, Atlanta GA
Background: The MIST-VR (Mentice, Gothenberg, Sweden)
simulator has been validated as a training and assessment
tool for technical skills in laparoscopy. The purpose of this
study was to assess performance on the MIST-VR using a
large number of experienced laparoscopic surgeons. Methods:
Surgeons attending the SAGES 2004 Annual Meeting who had
performed more than 100 laparoscopic procedures volunteered
to participate and were tested in the SAGES Learning
Center. All subjects performed two consecutive trials of the
MIST-VR Core Skills 1 Program (acquire place, transfer place,
traversal, withdrawal insert, diathermy task, manipulate
diathermy). Trial 1 was considered a ?warm-up? and Trial 2
functioned as the test trial proper. The mean performance
results were analyzed for differences from Trial 1 to Trial 2
using a paired t-test. Correlations between simulator performance
and demographic information (i.e. age, experience, etc.)
were made using a Pearson?s Correlation Coefficient r.
Results: 57 surgeons participated in the study, 42 of which had
complete data for both Trials. Average age was 42±8 years,
average laparoscopic surgery experience was 8.5±5 years and
1160±1250 cases, and 16 surgeons (38%) had prior MIST-VR
experience.
The strongest predictors of performance were previous MIST-
VR experience (r= -0.63, p<0.0001), and younger age (r=0.36,
p<0.02). No correlations were seen between MIST scores
and years of laparoscopic experience (r=0.19, p=0.23) or number
of laparoscopic procedures (r=-0.07, p=0.64), but greatest
improvements in scores from Trial 1 to Trial 2 were seen in
surgeons with no prior MIST-VR experience. Conclusions:
Large-scale assessment of surgeons’ laparoscopic skills
is possible using MIST-VR. There is a learning curve associated
with the simulator, and should be taken into account when
establishing performance criteria. Performance appears to be
independent of laparoscopic experience and correlates well
with prior MISTexperience
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