Using Surgical Video to Improve Technique and Skill

摘要

Although the recent quality improvement efforts have made considerable gains in improving perioperative care, these approaches largely ignore the details of what occurs during the operation itself. It is generally accepted that what occurs at the hands of the surgeon during a procedure has significant influence on patient outcomes. However, objectively assessing surgeon performance in the operating room has been difficult. As a result, surrogate measures, such as procedural volume, have served as proxies for operative proficiency.1 Recently, enthusiasm has been growing to tackle the challenges of directly evaluating and improving surgeon performance using intraoperative video. This work with practicing surgeons builds on the previous experience of using video to assess laparoscopic skills among residents.2,3 Illustrating this strategy, a recent high-profile study in bariatric surgery demonstrated that higher peer ratings of surgical skill—assessed by video analysis of performance during laparoscopic gastric bypass—were associated with lower rates of postoperative adverse events.4 Although it may seem obvious that greater skill would be associated with improved outcomes, this was the first study to demonstrate that variations in technical skill could be reliably measured by peer evaluation of practicing surgeons. Perhaps most importantly, this study was the first to definitively link peer ratings of skill directly with patient outcomes. This study has only scratched the surface of using video analysis to improve intraoperative performance. Video analysis affords the opportunity to study both surgical technique (ie, the details of how an operation is conducted) and surgical skill (ie, how well a surgeon performs a procedure). This strategy may be particularly applicable for technically complex procedures that already have the capability to capture video (eg, advanced laparoscopy, robotic surgery, video-assisted thoracoscopic surgery). Furthermore, this work could also be extended to open procedures using other video-recording modalities. VIDEO ANALYSIS TO STUDY SURGICAL TECHNIQUE Although surgical technique has traditionally been studied using operative reports and surveys, evidence suggests that these may not be reliable.5 Relying on a surgeon's perception of operative events presents a major barrier to studying technique. Perceptual gaps may arise when there is a disconnect between what the surgeons think they are doing and what they are actually doing during an operation. For example, surgeons may state in their operative note that they performed the “critical view of safety” during a laparoscopic cholecystectomy. However, in some cases, they may not actually achieve this, creating a gap between the surgeon's perception of events and the safest technique. Addressing these subjective sources of error using surgical video—which demonstrates exactly what the surgeon did during the procedure—may be an important, but previously overlooked, opportunity for improving a surgeon's performance. Video analysis would also offer a novel scientific approach to understanding how the details of the operation link to both short- and long-term outcomes. For example, with a common bariatric surgery procedure, laparoscopic sleeve gastrectomy, there is lack of consensus about which techniques result in the lowest complication rates and best long-term outcomes. The Michigan Bariatric Surgical Collaborative (MBSC) has launched a statewide initiative to use video to study the details of surgical technique with this procedure. Surgeons will upload videos to a web-based review program, and peer surgeons will provide evaluations using a standardized instrument. These assessments will then be linked to patient outcomes to identify the best “macro” (ie, global steps of the operation) and “micro” techniques (ie, detailed technical steps of the operation) for performing the procedure. In addition to perioperative outcomes, it may also be possible to link d