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Surgical Endoscopy

, Volume 28, Issue 5, pp 1535–1544 | Cite as

International consensus on safe techniques and error definitions in laparoscopic surgery

  • Esther M. BonrathEmail author
  • Nicolas J. Dedy
  • Boris Zevin
  • Teodor P. Grantcharov
Article

Abstract

Background

Definitions of errors and poor technique in laparoscopic surgery are lacking in modern clinical practice. As a result, educators often base their teaching on personal experience and individual preferences. The objective of this study was to achieve expert consensus regarding these definitions in order to provide a framework for a standardized approach to teaching safe technique and avoiding common errors in laparoscopic surgery.

Methods

A Delphi survey was conducted with an international panel of experts in laparoscopic surgery. Survey items for definitions and examples of errors and resulting injuries (events) were derived from literature reviews and procedural observations. An online platform was used to administer the survey. Experts were requested to rate their level of agreement regarding survey items on a 5-point Likert-type scale; additional comments were facilitated through free-text entries. Consensus was defined as Cronbach’s α > 0.70. Items that were rated ≥3 (“somewhat agree”) by 75 % or more of the panel were included in the consensus list. The Delphi process was continued until all subsections of the survey met the defined consensus level.

Results

Two survey rounds were completed with 33 experts from 12 countries (round 1) and 25 experts from nine countries (round 2). Overall consensus was high for both rounds (α = 0.9). Seventeen definitions and 39 examples of errors and events were included in the final consensus list.

Conclusions

Standardized definitions and examples of technical errors in laparoscopic surgery were established using a consensus-based approach. These definitions can serve as uniform nomenclature and can be used by educators as a reference guide to ensure standardization in surgical training and performance assessment.

Keywords

Education Laparoscopic surgery Technical error Adverse event 

Notes

Acknowledgments

We thank the members of the expert panel for lending their expertise to the consensus process. These members include Hendrik J. Bonjer, Nicolas Christou, Liane S. Feldman, Peter Funch Jensen, Michel Gagner, Hans Lönroth, Joseph Mamazza, Mario Morino, Torsten Olbers, John Paige, Raul J. Rosenthal, Marlies Schijven, Christopher M. Schlachta, Nathaniel J. Soper, Dimitrios Stefanidis, Shawn Tsuda, Markus Utech, Bruce Wolfe, Tonia M. Young-Fadok, as well as those who wish to remain anonymous. This work was supported by an educational research Grant from Johnson & Johnson Medical Companies Canada and the Ontario Research Fund (ORF) (Drs. Bonrath, Dedy, and Grantcharov). Dr. Zevin is supported by the Royal College of Physicians and Surgeons of Canada Fellowship for Studies in Medical Education.

Disclosures

Esther M Bonrath, Nicolas J Dedy, Boris Zevin, and Teodor P Grantcharov have no conflicts of interest to disclose.

References

  1. 1.
    Dent TL (1991) Training, credentialling, and granting of clinical privileges for laparoscopic general surgery. Am J Surg 161:399–403PubMedCrossRefGoogle Scholar
  2. 2.
    Tompkins RK (1990) Laparoscopic cholecystectomy. Threat or opportunity? Arch Surg 125:1245PubMedCrossRefGoogle Scholar
  3. 3.
    Royston CM, Lansdown MR, Brough WA (1994) Teaching laparoscopic surgery: the need for guidelines. BMJ 308:1023–1025PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Society of American Gastrointestinal and Endoscopic Surgeons SAGES (1991) Granting of privileges for laparoscopic general surgery. Am J Surg 161:324–325CrossRefGoogle Scholar
  5. 5.
    European Association for Endoscopic Surgery (1994) Training and assessment of competence. Surg Endosc 8:721–722CrossRefGoogle Scholar
  6. 6.
    Kron IL (2011) Surgical mentorship. J Thorac Cardiovasc Surg 142:489–492PubMedCrossRefGoogle Scholar
  7. 7.
    Abboudi M, Ahmed K, Kirby R, Khan MS, Dasgupta P, Challacombe B (2011) Mentorship programmes for laparoscopic and robotic urology. BJU Int 107:1869–1871PubMedCrossRefGoogle Scholar
  8. 8.
    Entezami P, Franzblau LE, Chung KC (2012) Mentorship in surgical training: a systematic review. Hand (N Y) 7:30–36CrossRefGoogle Scholar
  9. 9.
    Cuschieri A (2003) Medical errors, incidents, accidents and violations. Minim Invasive Ther Allied Technol 12:111–120PubMedCrossRefGoogle Scholar
  10. 10.
    Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP (2013) Defining technical errors in laparoscopic surgery: a systematic review. Surg Endosc 27(8):2678–2691PubMedCrossRefGoogle Scholar
  11. 11.
    Duffield C (1993) The Delphi technique: a comparison of results obtained using two expert panels. Int J Nurs Stud 30:227–237PubMedCrossRefGoogle Scholar
  12. 12.
    Hsu CC, Sandford BA (2007) The Delphi technique: making sense of consensus. PARE 12(10):1–8Google Scholar
  13. 13.
    Palter VN, MacRae HM, Grantcharov TP (2011) Development of an objective evaluation tool to assess technical skill in laparoscopic colorectal surgery: a Delphi methodology. Am J Surg 201:251–259PubMedCrossRefGoogle Scholar
  14. 14.
    Graham B, Regehr G, Wright JG (2003) Delphi as a method to establish consensus for diagnostic criteria. J Clin Epidemiol 56:1150–1156PubMedCrossRefGoogle Scholar
  15. 15.
    Williams CK, Carnahan H (2013) Development and validation of tools for assessing use of personal protective equipment in health care. Am J Infect Control 41:28–32PubMedCrossRefGoogle Scholar
  16. 16.
    Pastor AC, Osman F, Teitelbaum DH, Caty MG, Langer JC (2009) Development of a standardized definition for Hirschsprung’s-associated enterocolitis: a Delphi analysis. J Pediatr Surg 44:251–256PubMedCrossRefGoogle Scholar
  17. 17.
    Morgenstern L (2005) A continuing challenge: the training of laparoscopic surgeons. Surg Innov 12:289–290PubMedCrossRefGoogle Scholar
  18. 18.
    Aggarwal R, Moorthy K, Darzi A (2004) Laparoscopic skills training and assessment. Br J Surg 91:1549–1558PubMedCrossRefGoogle Scholar
  19. 19.
    Zendejas B, Brydges R, Wang AT, Cook DA (2013) Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med 28(8):1078–1089PubMedCrossRefGoogle Scholar
  20. 20.
    Nunobe S, Hiki N, Tanimura S, Nohara K, Sano T, Yamaguchi T (2013) The clinical safety of performing laparoscopic gastrectomy for gastric cancer by trainees after sufficient experience in assisting. World J Surg 37:424–429PubMedCrossRefGoogle Scholar
  21. 21.
    Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, Marteau T (1998) Consensus development methods, and their use in clinical guideline development. Health Technol Assess 2:i–iv, 1–88PubMedGoogle Scholar
  22. 22.
    Linstone HA, Turoff M (eds) (1975) The Delphi method: techniques and applications. Addison-Wesley, BostonGoogle Scholar
  23. 23.
    Delbecq AL, Gustafson DH, Van de Ven AH (1975) Group techniques for program planning: a guide to nominal group and Delphi processes. Scott Foresman, GlenviewGoogle Scholar
  24. 24.
    Powell C (2002) The Delphi technique: myths and realities. J Adv Nurs 41:376–382CrossRefGoogle Scholar
  25. 25.
    Jones J, Hunter D (1995) Consensus methods for medical and health services research. BMJ 311:376–380PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Witkin BR, Altschuld JW (1995) Planning and conducting needs assessments: a practical guide. Sage Publications, Thousand OaksGoogle Scholar
  27. 27.
    Goodman CM (1987) The Delphi technique: a critique. J Adv Nurs 12:729–734PubMedCrossRefGoogle Scholar
  28. 28.
    Bonrath EM, Zevin B, Dedy NJ, Grantcharov TP (2013) Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg 100(8):1080–1088PubMedCrossRefGoogle Scholar
  29. 29.
    Joice P, Hanna GB, Cuschieri A (1998) Errors enacted during endoscopic surgery—a human reliability analysis. Appl Ergon 29:409–414PubMedCrossRefGoogle Scholar
  30. 30.
    Talebpour M, Alijani A, Hanna GB, Moosa Z, Tang B, Cuschieri A (2009) Proficiency-gain curve for an advanced laparoscopic procedure defined by observation clinical human reliability assessment (OCHRA). Surg Endosc 23:869–875PubMedCrossRefGoogle Scholar
  31. 31.
    Tang B, Hanna GB, Joice P, Cuschieri A (2004) Identification and categorization of technical errors by observational clinical human reliability assessment (OCHRA) during laparoscopic cholecystectomy. Arch Surg 139:1215–1220PubMedCrossRefGoogle Scholar
  32. 32.
    Tang B, Hanna GB, Bax NM, Cuschieri A (2004) Analysis of technical surgical errors during initial experience of laparoscopic pyloromyotomy by a group of Dutch pediatric surgeons. Surg Endosc 18:1716–1720PubMedCrossRefGoogle Scholar
  33. 33.
    McKee M, Priest P, Ginzler M, Black N (1991) How representative are members of expert panels? Qual Assur Health Care 3:89–94PubMedCrossRefGoogle Scholar
  34. 34.
    Kastein MR, Jacobs M, Van der Hell RH, Luttik K, Touw-Otten FWMM (1993) Delphi, the issue of reliability: a qualitative Delphi study in primary health care in the Netherlands. Technol Forecast Soc Change 44:315–323CrossRefGoogle Scholar
  35. 35.
    Fink A, Kosecoff J, Chassin M, Brook RH (1984) Consensus methods: characteristics and guidelines for use. Am J Public Health 74:979–983PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Mead D (1991) An evaluation tool for primary nursing. Nurs Stand 6:37–39PubMedGoogle Scholar
  37. 37.
    de Villiers MR, de Villiers PJ, Kent AP (2005) The Delphi technique in health sciences education research. Med Teach 27:639–643PubMedCrossRefGoogle Scholar
  38. 38.
    Okoli C, Pawlowski SD (2004) The Delphi method as a research tool: an example, design considerations and applications. Inform Manage 42:15–29CrossRefGoogle Scholar
  39. 39.
    The American Heritage Dictionary of the English Language. http://www.ahdictionary.com/word/search.html?q=error. Accessed 12 Dec 2013
  40. 40.
    Kohn LT, Corrigan J, Donaldson MS (eds) (2000) To err is human: building a safer health system, 6th edn. National Academies Press, WashingtonGoogle Scholar
  41. 41.
    Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA (2007) Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg 246(5):705–711PubMedCrossRefGoogle Scholar
  42. 42.
    Barach P, Johnson JK, Ahmad A, Galvan C, Bognar A, Duncan R, Starr JP, Bacha EA (2008) A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. J Thorac Cardiovasc Surg 136(6):1422–1428PubMedCrossRefGoogle Scholar
  43. 43.
    Pugh C, Plachta S, Auyang E, Pryor A, Hungness E (2010) Outcome measures for surgical simulators: is the focus on technical skills the best approach? Surgery 147(5):646–654PubMedCrossRefGoogle Scholar
  44. 44.
    Hamad GG, Brown MT, Clavijo-Alvarez JA (2007) Postoperative video debriefing reduces technical errors in laparoscopic surgery. Am J Surg 194(1):110–114PubMedCrossRefGoogle Scholar
  45. 45.
    Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky DA 3rd, Ramel S, Smith CD, Arvidsson D (2007) Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 193(6):797–804PubMedCrossRefGoogle Scholar
  46. 46.
    Reason JT (1990) Human error. Cambridge University Press, Cambridge, p xv, 302CrossRefGoogle Scholar
  47. 47.
    Tang B, Hanna GB, Cuschieri A (2005) Analysis of errors enacted by surgical trainees during skills training courses. Surgery 138(1):14–20PubMedCrossRefGoogle Scholar
  48. 48.
    Sarker SK, Chang A, Vincent C, Darzi AW (2005) Technical skills errors in laparoscopic cholecystectomy by expert surgeons. Surg Endosc 19(6):832–835PubMedCrossRefGoogle Scholar
  49. 49.
    Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, Satava RM (2002) Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 236(4):458–463 discussion 463–454PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Esther M. Bonrath
    • 1
    • 2
    Email author
  • Nicolas J. Dedy
    • 1
    • 2
  • Boris Zevin
    • 3
  • Teodor P. Grantcharov
    • 1
    • 2
    • 3
  1. 1.Institute of Medical ScienceUniversity of TorontoTorontoCanada
  2. 2.Division of General SurgerySt. Michael’s HospitalTorontoCanada
  3. 3.Department of SurgeryUniversity of TorontoTorontoCanada

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