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As minimally invasive surgery has become increasingly high-tech, it's fair to wonder if the complexity of laparoscopy has outpaced the skills that a surgeon needs to safely perform it. You suspect so when you review the dozens of malpractice lawsuits stemming from lap cases gone wrong, like the cholecystectomy in which the surgeon failed to properly dissect the area of surgery, misidentified the critical view, and failed to recognize that he dissected the common bile duct and cystic duct. Or when you see the human- and equipment-related errors occurring with alarming regularity. Or when you hear Robert Andrews, MD, the instructor of surgery at Beth Israel Deaconess Medical Center in Boston, Mass., share the shock he felt when he realized during a recent training session that many skilled laparoscopic surgeons were never schooled in the proper use of the most basic tool.
"What we discovered is that a good portion of highly trained surgeons — we're talking chief residents — didn't know how to properly load and unload a surgical stapler," says Dr. Andrews. "Laparoscopic equipment is very effective, but without adequate training, surgeons can really hurt someone with it."
Tools or weapons?
Giving your surgeons the tools and technologies they need to succeed is important, but so is making sure they're adequately trained to use them. "You're working with high-functioning video equipment, state-of-the-art instrumentation and lots of high-end supplies," says Charlotte Guglielmi, RN, BSN, MA, CNOR, the perioperative nurse specialist at Beth Israel. "While the surgical team is focused on making sure the technology is plugged in and connected properly, it's easy to lose sight of what matters most — patient safety."
SURGEON'S VIEW
Sight vs. Touch:
The Challenge of Laparoscopic Surgery
Why is laparoscopic surgery so difficult to perform? "First, you're working in 2 dimensions," says Jeffrey W. Hazey, MD, associate professor of general surgery at Ohio State University Medical Center in Columbus. "We see in stereoscopic, so making the adjustment to working with images on a 2-dimensional screen is a challenge."
That surgeons lose their sense of touch by trading in scalpels for laparoscopes only heightens the difficulty of performing incredibly intricate maneuvers through ports that are getting smaller in size and fewer in number. "Surgeons need to replace tactile feedback with visual feedback," says Dr. Hazey.
He believes laparoscopic surgeons will eventually operate in 3D once device manufacturers put stereoscopic cameras on the tips of 5mm and 10mm laparoscopes, at a reasonable price point. "You're looking at retooling hundreds of thousands of laparoscopes and video units," he says. "That's a big investment for the surgical community."
Until 3D views in the OR become commonplace (several surgeons we talked to believe that's where imaging technology will inevitably end up), docs need to make do with high-def video, which at this point is becoming standard in minimally invasive ORs. "The advancements of high-def imaging over the past 12 years or so has been outstanding," says Dr. Hazey, adding that HD technology actually lets him see better with a laparoscope than during open procedures performed in the foregut or on obese patients.
— Daniel Cook
The problem, says Daniel B. Jones, MD, MS, FACS, professor of surgery at Harvard Medical School and Beth Israel's chief of minimally invasive surgical services, is that technology is moving faster than educational efforts. "Anyone can find the 'on' button on a device, but they may have no idea what they're doing with it," says Dr. Jones, who's particularly concerned with improving the safety of surgical energy devices used to cut and coagulate tissue. "We're only now starting to understand the physics of the technology and beginning to teach people how to use these tools so they don't become weapons."
Generation gap
Complications related to laparoscopic techniques aren't widespread, says Jeffrey W. Hazey, MD, associate professor of general surgery at Ohio State University Medical Center in Columbus. He believes that reported mishaps are "sometimes magnified because of the differences in practice among various surgeons." Besides, he says, looking at complication rates alone can be somewhat misleading. "Bile duct injury rates, for example, increase when patients have acute gallbladder inflammation."
Dr. Hazey points out the surgical community saw a big uptick in common bile duct injuries when surgeons first started performing lap choles. As surgeons became more familiar with the technique and instrumentation improved, those injuries rates began to drop. "But some people argue they haven't dropped enough, back down to pre-laparoscopic rates," says Dr. Hazey. "What's important is that we do all we can to get the rate as close to zero as realistically possible."
THERMAL ENERGY
Preventing Stray Electrosurgical Burns During Laparoscopy
Stray electrical burns are laparoscopy's most dangerous complication, most often occurring out of the surgeon's field of view and damaging non-targeted tissues or organs. The results can be fatal, as in the case of sepsis resulting from a bowel perforation that isn't detected until days after the patient is discharged.
Most electrosurgical burns are undetected at the time of injury because they occur beyond the surgeon's field of view. During laparoscopic surgery, several instruments are inserted through abdominal wall ports. Keep in mind that 90% of the surgeon's laparoscope is hidden from the surgeon's view. This is why it's not uncommon for stray electrosurgical current to unknowingly pass through an electrosurgical probe and burn through patient tissue and organs. The surgeon, operating at the intended site, sends a 700 ?C stray spark to non-targeted tissue. Stray energy burns can cause necrosis of the bowel wall, leading to perforation.
To minimize the chances of laparoscopic burns:
- Switch to a different energy source, such as a harmonic scalpel or bipolar energy.
- Use active electrode monitoring, which shields and monitors for both insulation failure and excessive capacitive coupling.
- Electronically test before and after each procedure for insulation failure. Note that testing provides no protection against capacitive coupling.
According to 4 surgeon-initiated studies, the prevalence of a laparoscope having insulation failure is 21.6%, meaning there's a 1 in 5 chance of your surgeon being handed an instrument with insulation failure. Those same studies found that 57% of the insulation defects couldn't be seen with the naked eye. "It's a design defect, not surgeon technique," says Roger Odell, chairman of Encision, makers of laparoscopes with active electrode monitoring.
— Dan O'Connor
A new generation of surgeons who are expert in minimally invasive surgery leave patients in less post-op pain and able to return to normal life activities in a matter of days instead of weeks. Gallbladders, for example, have gone from requiring a 5-day post-op hospital stay to being performed in the outpatient setting. "It might take another 10 or 15 years until older physicians retire and we see a full compliment of surgeons in the workplace who are trained in advanced laparoscopic techniques," says Dr. Hazey.
There are real financial and time barriers for established surgeons who would have to leave lucrative private practices to seek training on advanced laparoscopic platforms, including robotics, that lead to safer surgery and better outcomes, says Dr. Andrews. He believes device manufacturers might be driving surgeon preferences instead of the other way around. "The industry identifies surgeons who will utilize the technology and preferentially trains them."
A surgeon must be willing to devote time and energy to advance his training, says John Marks, MD, of Marks Colorectal Surgical Associates in Wynnewood, Pa. "The mastery sought will ultimately reflect well upon his reputation and hopefully pay him back in the long run."
CUSTOM CHECKLIST
SAGES and AORN Team Up to Improve MIS Safety
AORN and the Society of American Gastrointestinal and Endoscopic Surgeons have teamed up to develop the Minimally Invasive Surgery Safety Checklist, a tool that addresses equipment preparation and staff responsibilities unique to laparoscopic surgery.
The checklist hits on critical steps that often lead to mishaps during surgery if skipped, says Charlotte Guglielmi, RN, BSN, MA, CNOR, perioperative nurse specialist at Beth Israel Deaconess Medical Center in Boston, Mass. It walks circulating nurses and scrub personnel through important safety checks such as ensuring video monitors are properly positioned, electrosurgical units are functioning and proper-sized trocars and laparoscopes are ready for use.
Checklists enhance communication and remind people how to function when stressful situations can cause unintentional omissions of vital safety measures," says Ms. Guglielmi. "They also put redundancy and standardization into workflows, which makes sure things happen that need to get done."
Running through the checklist before procedures start creates a shared mental model when things go awry, she explains. "To ensure best outcomes, you need to make sure high-functioning teams use the right devices at the right time on the right patient."
— Daniel Cook
ON THE WEB Access the SAGES-AORN Minimally Invasive Surgery Safety Checklist at tinyurl.com/7aqxslq
Pressure to perform
Is minimally invasive surgery filled with hotshot cowboys pushing the limits of safety? No, there are scores of talented surgeons operating with patients' best interests in mind. But perhaps device manufacturers, physicians, nurses and facility leaders need to pump the brakes on surgical innovations, choosing instead to advance at a comfortable pace. "There has to be some sort of system in place to train surgeons and nurses on new technology as it's introduced to reduce incidences of human error," says Dr. Andrews. "A mix of newer technology and adequate education makes laparoscopic surgery safer."
Dr. Jones' views on the industry's response to surgical energy safety offer direction: "It's very easy to say that surgeons and nurses have ignored this issue," he says. "Or we can look at it in a different light, that as we learned more about the physics of this technology and the injuries it can cause, we've gotten together to produce a really effective educational process."
In the end, surgeons must place patients' needs above their own, be courageous enough to take on difficult challenges and humble enough to recognize what lies outside of their skill levels, says Dr. Marks. "The issue is not that a surgeon cannot keep up with the technology," he adds, "but if a surgeon is utilizing equipment that he is unfamiliar with in an effort to keep up with others in the field, that's a personal failure and a failure for the profession. The basic mantra for the surgeon must be that the goal is for the operation to be performed perfectly, not necessarily laparoscopically." OSM
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