Abstract
Background
The adoption of laparoscopic pyloromyotomy (LPM) by pediatric surgeons has been limited due to concerns about long execution times and higher-than-expected morbidity. The aim of the present study was to examine the performance of LPM by pediatric surgeons during the initial stages of their experience.
Methods
Complete videotapes of 50 early LPM performed in one hospital were subjected to Observational Clinical Human Reliability Analysis (OCHRA) by an independent team.
Results
This series had a total morbidity of 6% (one intraoperative bleed, one gastric perforation, one incomplete pyloromyotomy). Using OCHRA, we identified 77 consequential and 233 inconsequential errors (mean of 6 ± 5.4 per operation, 16.7% total error probability) during an average operative time of 29.8 min. Eighty percent of the errors were of the execution type. A high probability of error was observed with the use of the following key instruments: holding graspers (68%), retractable blade (79%), and splitting forceps (77%). The OCHRA system confirmed that task III was the hazard zone for LPM. Excessive force (task III) resulted in gastric perforation and bleeding from the pyloric mass. Movement in the wrong direction and misorientation in tissue planes were the external error modes underlying misaligned cuts of the pyloric mass and poor tissue splitting (task zones II and III).
Conclusions
This early series of LPM was associated with an appreciable execution error rate, largely due to the poor functionality of the specific instruments used for the procedure. Human factors identified by the external error modes played a subsidiary but important role, underscoring the importance of skills training and experience (proficiency-gain curve).
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References
M Caceres D Liu (2003) ArticleTitleLaparoscopic pyloromyotomy: redefining the advantages of a novel technique JSLS 7 123–127 Occurrence Handle12856842 Occurrence Handle3015479
BT Campbell K McLean DC Barnhart RA Drongowski RB Hirschl (2002) ArticleTitleA comparison of laparoscopic and open pyloromyotomy at a teaching hospital J Pediatr Surg 37 1068–1071 Occurrence Handle10.1053/jpsu.2002.33846 Occurrence Handle12077773
MK Chen KP Schropp TE Lobe (1996) ArticleTitleComplications of minimal-access surgery in children J Pediatr Surg 31 1161–1165 Occurrence Handle1:STN:280:DyaK2s%2Fhs1Kgsg%3D%3D Occurrence Handle10.1016/S0022-3468(96)90109-8 Occurrence Handle8863256
JB Cooper RS Newbower RJ Kitz (1984) ArticleTitleAn analysis of major errors and equipment failures in anesthesia management: consideration for prevention and detection Anesthesiology 60 34–42 Occurrence Handle1:STN:280:DyaL2c7gt1CnsQ%3D%3D Occurrence Handle10.1097/00000542-198401000-00008 Occurrence Handle6691595
A Cuschieri (2003) ArticleTitleLest we forget the surgeon Semin Laparos Surg 10 141–148
B Dean M Schachter C Vincent N Barber (2002) ArticleTitleCauses of prescribing errors in hospital inpatients: a prospective study Lancet 359 1373–1378 Occurrence Handle10.1016/S0140-6736(02)08350-2 Occurrence Handle11978334
Embry DE (1986) SHERPA: a systematic human error reduction and prediction approach. International Topical Meeting on Advanced in Human Factors in Nuclear Power Systems, Knoxville, TN, USA, April 1986
T Fujimoto GJ Lane O Segawa S Esaki T Miyano (1999) ArticleTitleLaparoscopic extramucosal pyloromyotomy versus open pyloromyotomy for infantile hypertrophic pyloric stenosis: which is better? J Pediatr Surg 34 370–372 Occurrence Handle1:STN:280:DyaK1M7mtVWqsw%3D%3D Occurrence Handle10.1016/S0022-3468(99)90212-9 Occurrence Handle10052826
F Hulka MW Harrison TJ Campbell JR Campbell (1997) ArticleTitleComplications of pyloromyotomy for infantile hypertrophic pyloric stenosis Am J Surg 173 450–452 Occurrence Handle1:STN:280:DyaK2szhtFeksg%3D%3D Occurrence Handle10.1016/S0002-9610(97)00075-5 Occurrence Handle9168087
P Joice GB Hanna A Cuschieri (1998) ArticleTitleErrors enacted during endoscopic surgery — a human reliability analysis Appl Ergo 29 409–414 Occurrence Handle1:STN:280:DyaK1M%2FhtVyjuw%3D%3D Occurrence Handle10.1016/S0003-6870(98)00016-7
B Kirwan (1998) Human reliability assessment JR Wilson EN Corlett (Eds) Evaluation of human work: a practical methodology EditionNumber2nd Taylor & Francis London 921–968
LT Kohn JM Corrigan M Donalson (Eds) (2002) to err is human: building a safer health system National Academy Press Washington (DC)
LL Leape TA Brennan NM Laird AG Lawthers AR Localio BA Barnes L Herbert et al. (1991) ArticleTitleThe nature of adverse events in hospitalization patients: results of the Harvard Medical Practice study II N Engl J Med 324 377–384 Occurrence Handle1:STN:280:DyaK3M7gtFKksA%3D%3D Occurrence Handle10.1056/NEJM199102073240605 Occurrence Handle1824793
J Reason (1990) Human error Cambridge University Press New York Occurrence Handle10.1017/CBO9781139062367
W Senders NP Moray (Eds) (1991) Human error (cause, prediction, and reduction): analysis and synthesis Hillsdale (NJ) Lawrence Erlbaum
E Sitsen NMA Bax DC Zee (1998) ArticleTitleIs laparoscopic pyloromyotomy superior to open surgery? Surg Endosc 12 813–815 Occurrence Handle1:STN:280:DyaK1c3msleitA%3D%3D Occurrence Handle10.1007/s004649900719 Occurrence Handle9601996
Swain AD, Guttmann HE (1983) A handbook of human reliability analysis with emphasis on nuclear power plant applications. USNRC-Nureg/CR-1278. US Nuclear Regulatory Commission, Washington (DC)
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Tang, B., Hanna, G.B., Bax, N.M.A. et al. Analysis of technical surgical errors during initial experience of laparoscopic pyloromyotomy by a group of dutch pediatric surgeons . Surg Endosc 18, 1716–1720 (2004). https://doi.org/10.1007/s00464-004-8100-1
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DOI: https://doi.org/10.1007/s00464-004-8100-1