Category Archives: Discussion

Google Glass for Surgeons

I’ve been watching the Google Glass project for a while now thinking of possible applications in surgery.  Clearly the video output could be used to stream views to monitors within the room to allow all team members to see what the surgeon with the best view can see, and it would make it extremely easy to video record rare cases for use in teaching.

Use of the viewer seems like a double edge sword, as it may be incredibly useful when you want to see the patients vitals, or to review imaging such as CT scans under your own control while in a case it could be incredibly distracting. I’ll just have to try it out and see.

A couple of less obvious thoughts that I’ve had for uses:

1) Intraoperative visual consults: Obviously you gain a lot in surgery by touch, but if you just want another visual opinion, this could be easily done, and could easily be done with surgeons who are operating simultaneously wearing the glass.

2)Pathologists could send their camera output to the surgeon to demonstrate where the positive margin is.on the resected tumor.

3)Pseudo-Autonomy for residents.  The attending connects to the residents camera output to monitor the procedure progression and offer suggestions without actually having his hands in the field

4) Remote/Stealth Rounds – Have the intern or midlevel provider round with Glass on. Then document LGFG(Looks Good From Glass).

Anybody willing to spot me $1500 for a developer edition set of Glass would get a serious thank you.

Behind the Scenes Robot in the OR

GE is working on a robot that will run behind the scenes in the operating room. Their intent is to automate instrument transport and processing and hopefully will cut costs and demonstrate quality improvement effects unlike other robots in the operating room that still have controversy about their use. Part of this system will involve technology to identify surgical instruments via RFID during the collection process as well as building trays for future cases. I’m interested to see if the robot will participate in counting at the end of the case to standardize instrument counting and use the RFID as an extra layer of protection. The video is a little anti-climactic but explains the idea behind developing this technology for the OR.

Fluorescent Surgery

A surgical oncologists dream is to be able to see the extent of the tumor they are resecting while they are operating room. Experimental fluorescent molecules have the capability to make tumors light up in the operative field. Very similar to the Firefly system on the Da Vinci Robot, these molecules can be tagged to tumor cells which then glow when exposed to certain wavelengths of light.  While this may be huge for surgical oncologists, I am excited to see what happens when it becomes widely available and we find other uses for it.

Watch the TEDMED video below to see a possible future of surgical intervention:

Surgical Simulator Nightmare

Once open surgery is dead and it’s all NOTES, and IR interventions, we will have this as our open surgery simulator! I want to get my FOS(Fundamentals of Open Surgery) pin to go along with my FLS(Fundamentals of Laparoscopic Surgery) pin.

You have to hand it to the creators of the game, apparently they made the simulator in less than 48 hours.

You can play the game here, but it requires a plugin install.

Post-Surgical Emergency Department visits

I once had an attending physician on a busy service say that “If you don’t have a 20% re-consult rate on your consults you aren’t signing off fast enough.” After reading Postdischarge ED Visits Nearly as Frequent as Readmissions on the ACS Surgery News website I began to wonder if hospital administrators are going to start seeing post discharge emergency departments visits as “Never Events”. It just makes me wonder what is the acceptable rate of post discharge ED visits because as pressure goes up to decrease the length of stay it seems you are going to increase some of those ED visits.  Before I discharge patients I reiterate that before they go to the ED they need to call me, or if it’s an emergency they need to call me on the way in, mainly because I want to grab them out of the ED waiting room rather than having them wait several hours in a waiting room and get tests I wouldn’t have orered.  Despite all my efforts I still see patients go to the ED to get a simple question or to get issues resolved that easily could have been dealt with in clinic(sometimes being called to the ED from clinic to see these patients). I wonder if pressure on these metrics will have surgeons and hospitalists setting up their own urgent care setting that isn’t technically considered part of the ED to loophole this metric.

Randomized Controlled Trial: Laparoscopic Skills Program

A recent Annals of Surgery article reports a randomized controlled trial of a laparoscopic skills training program vs. conventional methods of training residents. The intervention program taught theoretical information about basic laparoscopy, and involved case based learning of the steps/techniques, relevant anatomy, possible complications and management of possible complications. Then it involved laparoscopic box training as well as use of the virtual reality simulator. They then compared these residents to the conventionally trained residents on their first five laparoscopic cholecystectomies and reported that the intervention group outperformed the conventionally trained residents and claim that they effectively moved the learn curve out of the operating room and into the skills lab.

No one is really surprised that more effort and more practice gave better results, but I think that residency is too short to spend a lot of time in a skills center. Ideally these kinds of basic skills training sessions should be done by 4th year medical students going into surgery so that they can hit the ground running once they have an MD behind their name.  Unfortunately, surgery residencies and medical schools aren’t likely to put the effort in to train a 4th year medical student that isn’t for sure doing their residency at that program. Maybe surgery residencies will reach out to incoming interns in there 4th year with online curriculum for the last 3 months of medical school.

 

Annals of Surgery: Validation of a Structured Training and Assessment Curriculum for Technical Skill Acquisition in Minimally Invasive Surgery: A Randomized Controlled Trial

 

I can’t wait to be an attending

A recent article in JACS demonstrates that trauma attendings can safely operate on their post call days. It’s abstract can be found here:

Outcomes of Operations Performed by Attending Surgeons after Overnight Trauma Shifts

I’m not quite sure how I feel about this study, the results, and the questions we are asking. I guess I’m glad to know that we have some evidence that we don’t all have to become shift workers.  But there seems to be more and more studies differentiating between residents and attendings lately, or atleast questioning impact of resident involvement. Such as this article, that I alluded to in my first post.

Resident Participation in Index Laparoscopic General Surgical Cases: Impact of the Learning Environment on Surgical Outcomes

It’s as if we are comparing residents and attendings as two seperate treatments, rather than realizing it takes one to get the other. I feel it won’t be long until we’ll have Level I evidence that we shouldn’t train residents and then residency training programs will be sued out of existence.  Oh well.  Just my two cents on this new trend i’ve noticed.

Surgical Resident Education – Operations Take Longer with Residents

Surgical Resident Education – Operations Take Longer with Residents

One of my favorite surgery related bloggers Skeptical Scalpel posted an article on General Surgery News. This post brought to my attention the JACS article in the January Issue that points out that based on a NSQIP query, resident involvement in cases increased the length of the procedure.  There are many reasons why this may be and I’m sure it will be argued about to great lengths.  We need to weigh out what an acceptable educational cost is and try to ensure that we do not exceed this cost. I think that much could be done in our current training model to ensure that operating time is used effectively.

I am reminded of an article that I came across that surveyed residents about the quality of teaching in the OR and that “faculty help to identify the resident’s personal educational operative goals preoperatively” in 18% of the cases, and  “discuss areas of improvement with residents” in 37% of cases.  I believe we need better education pre-op and post-op to make the intra-op teaching more efficient.