XXI CONGRESSO NAZIONALE SICOB
ATTUALITA’ E NUOVE PROSPETTIVE
IN CHIRURGIA BARIATRICA E
METABOLICA
G. Casella, D. Giannotti, G. Patrizi, G. Di Rocco, M. Marchetti, E. Soricelli, A. Redler
“SAPIENZA”
UNIVERSITA’ di ROMA
UOC CHIRURGIA GENERALE G
Direttore: Prof. Adriano Redler
I SIMULATORI LAPAROSCOPICI
Strumento valido e sicuro per l’acquisizione ed implementazione
delle competenze laparoscopiche.
Lap MentorTM
Simulatore laparoscopico dotato di force feedback con
visualizzazione realistica della cavità addominale.
.
Basic skill tasks:
Full procedures:
• manipulation of a 0 and 30-degree camera
• Cholecistectomy
• eye-hand coordination
• gastric by-pass
• clipping and grasping leaking hoses
• hernia repair
• two-handed maneuvers
• cutting
• electrocauterization
• objects traslocation.
OBJECTIVE ASSESSMENT
Total time
Accuracy rate
Economy of movements of left instrument
Economy of movements of right instrument
Average speed of instrument
Total path lenght of instrument
Safe dissection,
Time of unsafe coagulation
Complications
Bleeding
Non cauterized bleeding
Perforations
Etc...........
CONSTRUCT VALIDITY
1.
2.
3.
4.
5.
Face validity
Content validity
Construct validity
Concurrent validity
Predictive validity
Construct validity: fondamentale per valutare
il simulatore come strumento di training e
certificazione
Capacità di discriminare tra i diversi livelli di esperienza dei soggetti
esaminati.
NOVICE
EXPERT
• Ruolo comprovato nella valutazione delle procedure
BACKGROUND
laparoscopiche di base.
•Discussa la possibilità di distinguere la reale
esperienza del chirurgo in procedure di maggiore
complessità come il LRYGBP.
AIMS
Verificare la capacità del simulatore Lap-Mentor
(Simbionix) di riconoscere il diverso grado di
esperienza in procedure di laparoscopia avanzata e
valutarne il ruolo nella certificazione del chirurgo
nella chirurgia bariatrica.
As a results of the growing diffusion of bariatric surgery
and of increased patients’ demands, more and more surgeons
even without a specific training began to perform bariatric
advanced laparoscopic surgical procedures.
Reznick R, Regehr G, MacRae H, Martin J, McCulloch W.
Testing technical skill via an innovative ‘bench station’
examination.
Am J Surg. 1997;173:226-230.
Objective Structured Clinical Examination (OSCE)
Objective Structured Assessment of Technical Skills (OSATS)
using a global rating scale which consists of seven evaluation items
scored on a five point scale:
1.
2.
3.
4.
5.
6.
7.
respect for tissue
time/motion
Instrument handling
flow of operation,
knowledge of instruments
knowledge of procedure
use of assistants.
Matsuda T, Ono Y, Terachi T, et al.
The endoscopic surgical skill qualification system in
urological laparoscopy: a novel system in Japan.
J Urol. 2006;176:2168-2172
A system for reviewing unedited videotapes of laparoscopic
nephrectomies or adrenalectomies by utilizing simplified criteria to
assess the laparoscopic surgical skills of urologists
•Validated system of proficiency
assessment
•Two blinded experts
•Subjective evaluation
•Loss of attention
OBJECTIVE ASSESSMENT
Total time
Accuracy rate
Economy of movements of left instrument
Economy of movements of right instrument
Average speed of instrument
Total path lenght of instrument
Safe dissection,
Time of unsafe coagulation
Complications
Bleeding
Non cauterized bleeding
Perforations
Etc...........
STUDIO PROSPETTICO
20 CHIRURGHI
No VRLS experience
10 BARIATRIC GROUP
10 GENERAL GROUP
EYE-HAND COORDINATION TASK
CONFEZIONAMENTO GASTRIC POUCH (TASK 1)
ANASTOMOSI GASTRO-DIGIUNALE (TASK 2)
RISULTATI:
EYE-HAND COORDINATION TASK
General Group
Performance
Bariatric Group
Median
IQR
Median
IQR
P-value
total time (s)
53.5
(41.7-55.2)
52.5
(34.7-60.2)
0.8498
accuracy rate (%)
84.6
(69.3-90.0)
84.1
(72.9-89.9)
0.7050
EMRI
67.2
(59.0-70.6)
66.3
(55.4-69.6)
0.5453
EMLI
67.4
(54.6-75.6)
66.1
(57.0-71.4)
0.8205
metric
IQR: Interquartile range; EMRI: economy of movement of right instrument;
EMLI: economy of movement of left instrument
CONFEZIONAMENTO GASTRIC POUCH (TASK 1)
Pouch volume
General Group
Pouch volume (cc)
Unsafe dissection (%)
Times the linear cutter
was fired (n)
Fundus included in the
pouch (%)
Time of unsafe
coagulation (s)
Complications (n)
Bleeding (n)
Non cauterized
bleeding (n)
Pouch volume(cc)
Total time (s)
60
Median
50
40
901.5
30
20
48.3
10
0
47.2
3.5
40
(s)
Time of unsafe coagulation
(%)
Fundus included
Performance metric
30
29.4
20
30
26.5
10
25
20
0
0.0
15
10
5.5
5
1.00
Bariatric Group
IQR
Median
IQR
(711.2-1161.5)
820.0
(606.7-1443.5)
0.7913
(32.9-56.2)
22.1
(19.1-27.8)
0.0034
(39.2-63.8)
51.0
(40.8-59.5)
0.9397
3.0Group
Bariatric
(3.0-4.0)
0.5408
(2.9-14.9)
0.0034
(2.0-10.7)
0.0006
(0.0-0.0)
0.1462
Fundus 1included in the pouch
2
(2.7-5.0)
General
Group
(18.8-42.2)
8.4
Time
of unsafe coagulation
P-value
(14.5-43.7)
3.5
(0.0-0.2)
1
0.0
(2.0-8.0)
General
Group
0.0Group
Bariatric
(0.0-1.0)
0.0003
(1.0-1.2)
1
0.0
(0.0-0.0)
0.0006
General Group
2
2
Bariatric Group
YES
NO
YES
NO
P-value
Dissection of His angle
3
7
10
0
0.003
Pouch separated
8
2
10
0
0.474
ANASTOMOSI GASTRO-DIGIUNALE (TASK 2)
General Group
Performance metric
Bariatric Group
Median
IQR
Median
IQR
P-value
306.0
(265.7-518.2)
385.5
(291.5-454.0)
0.8501
Jejunum injurie (n)
3.5
(0.7-7.5)
5.5
(2.7-7.2)
0.3053
Punctures >1cm (n)
1.0
(0.0-1.0)
0.0
(0.0-0.2)
0.0285
Punctures not used (n)
0.0
(0.0-0.2)
0.0
(0.0-0.0)
0.1462
Total time (s)
IQR: Interquartile range
CONCLUSIONI
•Il chirurgo bariatrico risulta più accurato durante
l’esecuzione del GBP negli accorgimenti che influenzano i
risultati della procedura stessa come la preparazione
dell’angolo di His ed il volume della pouch.
CONCLUSIONI
•Il simulatore Lap-Mentor (Simbionix) è in grado di riconoscere l’esperienza
in procedure di chirurgia laparoscopica avanzata e potrebbe essere proposto
quale strumento di certificazione.
•L’ analisi dei parametri in cui si sono registrate le differenze più significative
tra i due gruppi, potrebbe suggerire quali esercizi risultino più utili nei
programmi di training per la formazione del chirurgo bariatrico.