Citations

Laparoendoscopic single-site surgery (LESS) is a new minimally invasive surgical technique that presents physical and mental challenges to surgeons. Currently, LESS procedures are commonly performed using surgical instruments designed for traditional multi-incision laparoscopic surgery. A pilot study was conducted to determine which laparoscopic instruments were the most efficient for LESS procedures. In a LESS surgical trainer, 24 novice users completed a simple surgical task using standard (non-articulating) straight laparoscopic graspers and two different articulating instruments. Task performance was scored based on completion time and the number of errors. Analyses showed that the use of the simpler straight instruments produced significantly faster times (p = 0.004 and p = 0.014) and higher task scores (p = 0.005 and p = 0.021) than the articulating instruments. These results suggest that standard laparoscopic hand instruments enable better novice performance for a basic LESS task.

This session will focus on lessons learned when developing solutions for real world problems in healthcare. Human factors (HF) practitioners bring unique knowledge, methods, and perspectives to work with clinicians to address numerous defects in the worksystem but require problem-solving skills that focus on solutions. The HF contribution may be in the area of process improvement (e.g., prevention of patient falls), systems design (e.g., designing crashcart), or identification of design flaws so robust intervention may be deployed (e.g., glucose meters). Six human factors practitioners who work within healthcare systems will present real world challenges which were discovered by HF methods, or which have heavy HF implications, but where direct HF influence on design lead to the ultimate effective solution. The session will be designed to lead to a discussion about how HF methods were adapted to individual problems at hand and to focus on developing solutions.

The Institute of Medicine lists investigations of the comparative effectiveness for minimally invasive surgical procedures as a research priority. As new minimally invasive procedures are developed, comparisons of the resulting workload contribute valuable information about the impact of the new procedures. Recent reports suggest that surgeon workload can influence patient outcomes. Measurements of stress and fatigue for the surgical team participating in a randomized NIH supported trial of single incision versus traditional laparoscopic cholecystectomy were obtained. These stress measures showed that the SURG-TLX was sensitive to the difficulty of the surgery. The SURG-TLX and a surgical difficulty score was obtained from the surgical team for 16 laparoscopic surgeries by surgical approach (8 SILC and 8 4-port) showed that for this small sample size, there were no statistically significant differences in length of surgery, degree of difficulty, nor patient considerations such as post-operative pain scores. In addition, no statistically significant differences in the individual Surg-TLX subscale scores or Surg-TLX total for the surgical team overall or for the surgeon alone by surgical platform. This is likely due to the small sample size reducing the power of the tests.

Background —The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) on long-term mortality rates in the presence of various demographic, clinical, and angiographic factors is uncertain in the population of patients suitable for both procedures. Methods and Results —In the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial and registry, 3610 patients who were eligible to receive PTCA and CABG were revascularized between 1989 and 1992. Multivariate Cox models were used to identify factors associated with 5-year mortality and cardiac mortality, with particular attention to factors that interact with treatment. Diabetic patients receiving insulin had higher mortality and cardiac mortality rates with PTCA compared with CABG (relative risk [RR] 1.78 and 2.63, respectively, P <0.001), and patients with ST elevation had higher cardiac mortality rates with CABG than with PTCA (RR 4.08, P <0.001). Factors most strongly associated with high overall mortality rates were insulin-treated diabetes, congestive heart failure, kidney failure, and older age. Black race was also associated with higher mortality rates (RR 1.49, P =0.019). Conclusions —A set of variables was identified that could be used to help select a revascularization procedure and to evaluate risk of long-term mortality in the population of patients considering revascularization.

Background There are few data comparing clinical outcome and potential indications for routine post–myocardial infarction cardiac catheterization and revascularization of patients who sustain a non–Q-wave versus Q-wave infarct after thrombolytic therapy. Methods and Results A secondary analysis of 2634 patients enrolled in the TIMI II trial with a first myocardial infarction was performed to determine 6-week and 1-year cardiac event rates and identify clinical and angiographic differences between the 1867 patients (70.9%) who evolved a Q-wave infarct and the 767 patients (29.1%) who sustained a non–Q-wave infarct after treatment with intravenous thrombolytic therapy. Male sex (85.3% versus 75.6%; P <.001) and anterior wall infarcts (53.8% versus 43.7%; P <.001) were more frequent in the Q-wave versus the non–Q-wave group. During recombinant tissue-type plasminogen activator (rTPA) infusion, a greater percentage of non–Q-wave patients (37.3% versus 23.5%; P =.001) had normalization of initial ST-segment elevation. Infarct-related artery patency (TIMI flow grade 2 or 3) ( P =.02), complete infarct-related artery reperfusion (TIMI 3 flow grade) ( P <.001), and the percentage of patients with a predischarge resting left ventricular ejection fraction >55% ( P <.001) were greater in the non–Q-wave group. New congestive heart failure during hospitalization developed more frequently in Q-wave patients (18.9% versus 11.6%; P <.001). After 42 days, the occurrences of reinfarction ( P =.76), death ( P =.76), and combined death or reinfarction ( P =.43) were similar in patients assigned to the invasive or conservative postlytic management strategy, regardless of infarct type. One-year mortality was 3.4% versus 4.4% for non–Q-wave versus Q-wave infarct type, respectively ( P =.25). Conclusions Angiographic and clinical differences were observed between patients who present with initial ST-segment elevation and evolve early non–Q-wave versus Q-wave myocardial infarcts after treatment with rTPA, heparin, and aspirin. Early mortality and adverse clinical cardiac events in these patients are not significantly different after a conservative compared with an invasive treatment strategy, regardless of whether the infarct type is non–Q wave or Q wave.