Background: Surgical checklists are in use as means to reduce errors for safer surgery. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. Aims: We aimed to formulate a performance based checklist and to study its effect on the surgical task performance of novice surgeons when applied during both, routine knot tying and simulated emergency laparoscopic tasks. We also aimed to study the effect of the performance based intra-procedural checklist in clinical environments during elective laparoscopic procedures as a way of error reduction mechanism and improvement of patient safety. Methods: The study was conducted in two settings, lab-based and clinical-based environments. The lab-based study was conducted during both routine and emergency tasks. Lab-based study- routine task: Twenty novices were randomised into two equal groups, those receiving paper feedback (control group), and those receiving paper feedback and the checklist that was applied at 20 seconds intervals (checklist group). The task involved performing laparoscopic double knots which were repeated over 5 separate stages. Human reliability assessment technique was used for error analysis on unedited video recordings of the tasks. Endpoints included number of errors, error probability (number of errors/number of knots), error types and number of completed knots. Non-parametric statistics were used for data analysis. Lab-based- emergency task: Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency surgical scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into 2 equal groups; those using the checklist (checklist group) and those without (control group). The checklist was applied by the trainees in the checklist group at 20 seconds intervals. The surgical performance was computed on eight predetermined technical factors. Clinical-based study: Surgical trainees in the general surgery at Tayside NHS were included in this study and required the attendance of a trainer during the procedure as per routine practice. Record year of trainees and previous experience on laparoscopic cholecystectomy were noted. Two elective laparoscopic cholecystectomies for each trainee were video-recorded without the use of the checklist, directly followed by 2 further operations after the introduction of the checklist. The unedited videos were analysed for error detection using human reliability analysis technique. Total number of errors per time during each procedure, total number of errors per number of instrument movements, total number of instrument movements per time and number of trainer intervention while per time were noted as assessment points. Results: Lab-based- routine task: 2341 errors were detected in 141 tasks, 408 subtasks and 2249 steps during the 5 stages. During the first stage, the errors were not significantly different between groups. The checklist group committed significantly fewer errors as compared to the control group during all the later 4 stages (p < 0.01). The checklist group had an enhanced learning curve as the last 4 stages showed significant fewer errors compared to the first stage (p < 0.05), while the control group showed no improvement. Error probability was significantly higher in the control group compared to the checklist group: median [IQR] 32.6 [25.89] vs 11.7 [10.72] (p < 0.01). Individual error types during each step of the laparoscopic task were identified. The checklist group performed better with fewer errors for all the error types. While, there was no significant difference in each of 'the lack of supination', 'tissue bite' and 'out of vision'; the differences in all the rest of error types were highly statistically significant (p < 0.01). Number of completed knots was not statistically different between the 2 groups. Lab-based- emergency task: The checklist group performed significantly better in 6 out of 8 technical factors when compared to the control group median [IQR]: Right instrument path length (m) 1.44 [1.22] vs 2.06 [1.70] (p= 0.029), and right instrument angular path (degree) 312.10 [269.44] vs 541.80 [455.16] (p= 0.014), left instrument path length (m) 1.20 [0.60] vs 2.08 [2.02] (p= 0.004), left instrument angular path (degree) 277.62 [132.11] vs 385.88 [428.42] (p= 0.017). The checklist group committed significantly fewer number of errors in the number of badly placed clips (p= 0.035) and number of dropped clips (p= 0.012). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p= 0.724), and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p=0.165). Clinical-based study: Participants performed statistically better with fewer number of errors per time with the application of the checklist compared to when no checklist was used respectively: Median [IQR] total number of errors 1.51 [0.80] vs 3.84 [1.42] (p=0.002), consequential errors 0.20 [0.12] vs 0.45 [0.42] (P=0.005), inconsequential errors 1.32 [0.75] vs 3.27 [1.48] (p=0.006) and total number of errors per number of instrument movements 0.16 [0.04] vs 0.29 [0.16] (p= 0.003). With the introduction of the checklist, the number of interventions by the trainer per time decreased from 2.79 [1.85] to 0.43 [1.208] (p=0.003) and the number of instrument movements per time decreased from 11.90 [5.34] to 10.38 [5.16] (p=0.04). Conclusions: We have developed standardised checklists to be applied during elective and emergency laparoscopic tasks. The performance based self-administered intra-procedural checklist had a significant accelerating effect on the acquisition of technical skills when applied by novices during a standardised laparoscopic lab-based routine task and improved the task performance during a simulated laparoscopic emergency scenario. The checklist enhanced the performance of surgical trainees and decreased the number of interventions of the trainer during laparoscopic cholecystectomy.

Trauma caused by grasping during laparoscopic surgery is something which will never be fully eradicated however efforts should be taken to reduce the potential to cause trauma by grasping. Tissue is often grasped with excessive forces for long periods of time during surgeries such as cholecystectomies and colectomies. This along with failed grasping actions and the occurrence of slip has been shown to damage the tissue. Design features often employed within graspers such as profiling and the occlusion mechanism of the instrument cause areas of high, uneven distribution of pressures on the tissue which can result in perforation or tissue tearing. By investigating these contributing factors, development of graspers with a low risk to cause damage this combined with actuating the grasping force should reduce the incidence of grasping trauma, currently at estimated at one incidence per procedure. These trauma events can lead to conversion to open surgery, peritonitis and even death. Development of an autonomous grasping instrument to detect and prevent slip by actuating the grasping force is reported. Piezoelectric sensors are used to detect incipient slip and slip events. A closed loop control system then reacts to these perceived slip events to prevent slip occurring by actuating the applied force by small increments to increase or decrease grasping force. This leads to a system in which only the required amount of force necessary to overcome pull force is applied to the tissue. Other areas of investigation to reduce tissue trauma are presented. In chapter 3 design features such as surface profiling and fenestrations are evaluated to determine the potential to cause damage. A variety of profiles and fenestrations are studied and each is reported by representing the applied force to retention force ratio which indicates how good the profile is at retaining tissue against a pull force. The aim of this study was to develop surface profiling which had a high retention force but a reduced number of high stress areas which can lead to tissue damage. Three new parallel action grasping designs are presented and evaluated using finite element analysis. Parallel action grasping is important in reducing tissue trauma as it distributes pressure evenly across the active grasping area as opposed to more conventional pivot style graspers which have high stress concentration areas in the proximal opening. Each area of study within the thesis addresses areas of concern which have been shown to cause tissue trauma and postulates viable solutions to reduce the incidences of tissue trauma during laparoscopic surgery with the ultimate aim of developing a deployable and autonomous grasping device which will detect and prevent slip.

Objectives: Study wanted to explore the factors that will affect the total medical expense in the patients who receive laparoscopic cholecystectomy (LC). We also to confer the influencing factor that will associate with the difference of reports the expense under the case payment system. Methods:Retrospective study . Collected from year 2003 to 2007, received LC in a general teaching hospital in Kaohsiung city. We also adopt the chart review and combined with the health insurance expense data to explore the important factors that were associated with total hospitalized expenses, declaration of expense differences, and profits. The methods of multiple linear and logistic regressions were needed. Results: 1539 subjects, 613 male and 926 female. The average age was 54.4 , and 1313 subjects were hospitalized from outpatient. All subject¡¦s average hospitalized days were 3.79 and medical expenses were 42528.1 dollars. The frequencies of the type of declaration about ¡¥not exceed¡¦, ¡¥exceed but actually¡¦, and ¡¥exceed but no actually¡¦ were 88.8%, 8.6%, and 2.6%, in sequence. The average declaration of expense differences was 14484.1 dollars. The significant factors that were associated with total hospitalized expenses were the age, surgical year, source of hospitalize, major symptom, combine disease, a complication after surgery, hospitalized days, type of declaration. In the other linear regression model, we found the age, surgery year, source of hospitalize, major symptom, high technology examination before surgery, combine disease, a complication after surgery, hospitalized days, and physician¡¦s surgery quantity per year had been statistically significant with the declaration of expense differences. For the odds of hospital¡¦s profits, the significant factors include the surgery year, source of hospitalize, major symptom, high technology examination before surgery, and hospitalized days. Conclusion: We found a few significant factors that were associated with dependent variable in three regression models in this study. The major factor is hospitalized days that were a stronger influence total hospitalized expenses, declaration of expense differences, and hospital¡¦s profits. The hospital¡¦s superintendent can carry on the management through the appropriate method to control the medical resource consumes.

Hysterectomy is the second highest frequency of gynecologic surgery. With limited medical resources, understanding of qualities and expenses of different types of surgery can be used as a reference for patients and hospital administrators in making related decisions. Therefore, the purpose of this study is to compare the outcomes between ¡§Total Abdominal Hysterectomy¡¨ and ¡§Laparoscopic Hysterectomy¡¨. Data sources are the health insurance report data files and charts of a regional teaching hospital. There were 114 cases between January 2006 and June 2010 at the sample hospital. Operating time, length of stay, and intra-operative blood loss between both types of hysterectomy are analyzed and compared by using t-test. Linear regression analysis is then used to examine the predictive factors that impact the outcomes of both types of surgery. The results indicate that, in terms of clinical results, laparoscopic hysterectomy takes 120.45 minutes on average, and total abdominal hysterectomy 104.35 minutes; laparoscopic hysterectomy requires an average of 4.73 days of hospital stay, and total abdominal hysterectomy 5.54 days; and finally, laparoscopic hysterectomy causes an average of intra-operative blood loss of 249.70cc, and total abdominal hysterectomy 290.21cc, laparoscopic hysterectomy costs an average of NT$69,268.85, and total abdominal hysterectomy NT$46,634.88. In regard to hospitalization costs, laparoscopic hysterectomy costs an average of NT$49,732.50, and total abdominal hysterectomy costs NT$42,066.27. Based on findings of this study, the following suggestions are proposed: (1) Laparoscopic hysterectomy can be safely and effectively used for patients with large uterine myoma or multiple myoma. (2)Hospitals should develop standardized medical treatment procedures; therefore, cost control would not be at the expense of the quality of care. Furthermore, standardization of medical treatment can be used to pinpoint whether there is any waste in the medical treatment process. Keywords: uterine myoma, hysterectomy, total abdominal hysterectomy, laparoscopic hysterectomy, outcome.

Abstract Background and Objectives: Since 1894, open appendectomy (OA) has been the treatment of choice for acute appendicitis. In 1981 Semm performed the first laparoscopic appendectomy (LA). More than 2 decades later, the benefits of LA are still controversial. The goal of the present investigation was to compare the effectiveness of LA and OA based on a large administrative (The Bureau of National Health Insurance, BNHI) Research Database. The source of data analyzed was the administrative claims data from the BNHI Research Database. Methods: The objective of this retrospective study was based on the ICD-9-CM procedure code of 4701 (Laparoscopic appendectomy, LA) and 4709 (Open appendectomy, OA) respectively from a database of 20 million insurance population, Separate analyses were performed for uncomplicated (ICD-9-CM, 540.9) and complicated (presence of appendiceal perforation or abscess; ICD-9-CM 540.0 and 540.1) appendicitis. Exclusive criteria were: (1) Average length of stay exceeds 3 S.D. (n=1,262). (2) Gender unmentioned (n=243). All these data will analyze in multiple dimensions including length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic (LA) and open appendectomy (OA) based on The Bureau of National Health Insurance (BNHI) database. Results: We enrolled 11,118 patients underwent LA and 47,725 patients underwent OA during 2004 to 2007. The prevalence of LA increases gradually from 6.97 per 100,000 populations in 2004 to 21 per 100,000 populations in 2007. The prevalence of OA decreases gradually from 57.5 per 100,000 populations in 2004 to 44.86 per 100,000 populations in 2007. Patients underwent LA (3.25¡Ó1.51day) have significant lower length of hospital stay than OA (3.57¡Ó1.49 day) (p<0.001). We also found the trend that the annual medical expenditure of LA increases gradually but OA decreases gradually. In general, LA spends higher medical expenditure than OA. With respect to medical expenditure, higher length of hospital stay and co-morbidity are associated with more medical expenditure significantly. Conclusions: LA is the current developing trend of surgical treatments for appendicitis. LA can reduce length of hospital stay significantly. OA can reduce the medical expenditure in Taiwan. In our opinion, the results represent the native data in Taiwan and are very important for a good administration of public resources distribution.

published_or_final_version / Surgery / Master / Master of Surgery

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Orientador: Maria Aparecida Coelho de Arruda Henry / Resumo: Em 40 coelhos machos foram realizados estudos eletromanométricos do esôfago segundo a técnica de puxada intermitente da sonda e infusão contínua dos catéteres com água destilada. Estes estudos permitiram a análise de dois parâmetros: amplitude da pressão no EIE (mmHg) e comprimento do EIE em condições basais (momento 1). Neste momento foi também realizada avaliação do peso corpóreo dos animais. Os 40 animais foram divididos em quatro grupo de 10, na dependência do procedimento cirúrgico realizado: Grupo 1: Fundoplicatura total laparotômica Grupo2 : Laparotomia mediana e dissecção da transição gastroesofágica Grupo 3: Fundoplicatura total laparoscópica Grupo 4: Pneumoperitôneo e dissecção da transição gastroesofágica No momento 2 (uma semana após os procedimentos cirúrgicos) foram realizados estudos eletromanométricos do esôfago e avaliação ponderal em todos os animais. Nos animais do grupo 1 (fundoplicatura laparotômica) foi observado aumento da amplitude da pressão e do comprimento do EIE (p<0,05). Naqueles do grupo 2 não foi observada alteração da amplitude e do comprimento do EIE (p>0,05). Nos coelhos do grupo 3 houve aumento da amplitude da pressão e do comprimento do EIE (p<0,05). Nos animais do grupo 4 não foi observada alteração dos parâmetros acima citados (p>0,01). Com relação ao peso corpóreo, foi observada redução do mesmo (p<0,05) apenas nos coelhos submetidos a fundoplicatura laparotômica (Grupo 1). Nos demais animais (Grupos 2, 3 e 4) não houve qualquer alteração do peso corpóreo na avaliação realizada uma semana após os procedimentos cirúrgicos (momento 2) / Abstract: Electromanometric studies of the esophagus were registered in 40 male rabbits, through the pull through technique and continuous infusion of the catheters with distilled water. These exams allowed us to measure the pressure width (mmHg) and the length (cm) of the lower esophageal sphincter (LES) in basal conditions (moment 1). The 40 animals were divided into four groups of 10, according to surgical procedure: Group 1: open total fundoplication Group 2: Median laparotomy and dissection of the gastroesophageal junction Group 3: laparoscopic total fundoplication Group 4: pneumoperitonium and dissection of the gastroesophageal junction. In moment two (one week after surgery) electromanometric studies of the esophagus and weight evaluation were performed in every animals. In group 1 (open fundoplication) an increase of pressure width and of LES was observed (p<0,05). In group 2, the pressure width and length of LES didn't present any alteration (p>0,05). In group 3 an increase of pressure width and length of LES was observed (p<0,05). In group 4, the pressure width and length LES didn't present any alteration (p>0,05). In respect to the weight evaluation, a decrease was observed in rabbits submitted to open fundoplication (p<0,05). In other animals (groups 2, 3 and 4) the weight didn't present any alteration in evaluation performed one week after surgery (moment 2) / Mestre

BACKGROUND: Uterine fibroids affect a quarter of the female population. The advent of minimally invasive gynecological surgery has revolutionized fibroid removal. The aims of this study were to analyze the variables correlated to myomectomies and establish predictive variable models. METHODS: From 2007 to 2009, 966 patients underwent myomectomy. 30 variables surrounding the myomectomies were analyzed. All variables were transformed into categorical variable and analyzed for normal distribution. The variables were cross-tabulated and analyzed for correlation using a Pearson Chi-Square statistic. Correlated variables underwent multinomial logistic regression analysis to obtain predictive models. Conclusion: A complete examination of all types of myomectomies support existing relationships between variables and provide novel correlations and predictions.

Submitted by CAIO DE FARIA TIOSSO null (caiotiosso@hotmail.com) on 2016-03-02T13:27:32Z No. of bitstreams: 1 tese definitiva pos PDF.pdf: 1935262 bytes, checksum: f8468503f23144f98facaedbd4067d40 (MD5) / Approved for entry into archive by Ana Paula Grisoto (grisotoana@reitoria.unesp.br) on 2016-03-04T13:02:28Z (GMT) No. of bitstreams: 1 tiosso_cf_dr_jabo.pdf: 1935262 bytes, checksum: f8468503f23144f98facaedbd4067d40 (MD5) / Made available in DSpace on 2016-03-04T13:02:28Z (GMT). No. of bitstreams: 1 tiosso_cf_dr_jabo.pdf: 1935262 bytes, checksum: f8468503f23144f98facaedbd4067d40 (MD5) Previous issue date: 2016-02-22 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Nos últimos anos a cirurgia minimamente invasiva vem ganhando cada vez mais adeptos por demonstrar vantagens inigualáveis em comparação à cirurgia convencional o que vem estimulando o desenvolvimento de instrumentais inovadores com potenciais aplicações na medicina veterinária. O presente estudo objetivou avaliar a técnica de portal único (SILSTM) para ovário-histerectomia videoassistida em cadelas, comparando-a à técnica laparoscópica videoassistida por “single-port” via endoscópio com canal de trabalho e com a técnica por celiotomia, verificando a curva de aprendizado, resposta inflamatória e comportamental, complicações trans-cirúrgicas e a perda sanguínea dos animais submetidos a estas técnicas. Foram avaliadas 30 fêmeas caninas, alocadas em três grupos com 10 animais em cada: ovário-histerectomia convencional por celiotomia (GI), ovário-histerectomia laparoscópica videoassistida por um único portal utilizando endoscópio com canal de trabalho (GII) e ovário-histerectomia laparoscópica com uso do dispositivo SILSTM (GIII). Foram avaliados os tempos cirúrgicos médios, numero de complicações trans e pós-cirúrgicas nos diferentes grupos, a intensidade da dor pós-operatória mediante aplicação da escalas de dor de Universidade de Melbourne, Glasgow e Morton e os níveis séricos da proteína C reativa e Interleucina-6 durante as primeiras 72 horas após o término dos procedimentos. A media de tempo obtidos foram de 30,20±6,41min para o grupo GI, 60,30±19,15 min para o grupo GII e 119,42±32,78 min para o grupo GIII. No GII ocorreram três complicações que não necessitaram de conversão da técnica cirúrgica e uma que necessitou de conversão e o GIII apresentou três complicações que necessitaram de conversão para a técnica aberta. Quanto ao sangramento transoperatório o grupo GI obteve a partir das gazes laparoscópicas uma média de 16,00±6,04g, o grupo GII 2,61±3,18g e o grupo GIII 3,79±1,78g. Ao final das 24 horas iniciais de avaliação, 90% dos animais do GI necessitaram de resgate analgésico, enquanto no GII e GIII, as porcentagens foram de 0% e 14,3%, respectivamente. As duas técnicas videoassistidas demonstram-se seguras e eficazes mesmo com a ocorrência de complicações. Os níveis de IL-6 e CRP atingem seu pico máximo em 12 e 24 horas respectivamente, e o aumento dessas parece estar diretamente relacionada ao tempo de cirurgia e não trauma gerado. O maior grau álgico observado nos pacientes do grupo GI demostra que a dor em procedimentos de OVH esta relacionada a manipulação visceral e a tração do pedículo ovariano. / Over the last few years, minimally invasive surgery is gaining more followers, by showing unparalleled advantages in front of conventional surgery. This fact has been stimulating the development of new instruments, potentially applicable on Veterinary Medicine. The current study aimed to evaluate the feasibility of a single portal technique (SILSTM) to ovariohysterectomy video assisted in bitches, comparing it to a video assisted technique by single-port using an endoscopy with work channel, and with celiotomy, assessing the learning curve, inflammatory and behavioral response, surgical complications and blood loss from animals subjected to these techniques. Thirty female dogs were evaluated, divided into 3 groups with 10 animals each (n=10): ovariohysterectomy by celiotomy (GI), laparoscopic ovariohysterectomy video assisted through a single-port using an endoscope with working channel (GII), and laparoscopic ovariohysterectomy using the SILSTM device (GIII). Mean surgical time, number of complications during and after surgery, pain level after surgery, and serum levels of C-reactive proteins (CRP) an Interleucin-6 (IL-6), were evaluated. Mean surgical times plus/minus standard deviations (SD) in minutes were 30.20±6.41, 60.30±19.15, and 119.42±32.78 for GI, GII and GIII, respectively. On GII, were noted three complications that didn’t need to be converted to celiotomy and one that needs, while GIII presented three complications that needed to be converted to celiotomy. Regarding blood loss, medians plus/minus SD in grams were 16.00±6.04, 2.61±3.18, and 3.79±1.78 for GI, GII and GIII, respectively. Twenty-four hours after the end of the procedures, 90% of animal from GI needed analgesic rescue, while in GII and GIII the values were 0% and 14.3%, respectively. Both video assisted techniques showed themselves secure and effectives, even with complications occurring. IL-6 and CRP levels showed a peak respectively on 12 and 24 hours after the procedures, and these increases seemed to be related with surgical time and not with injuries caused. The higher pain scores observed on GI animals showed that pain on ovariohysterectomy procedures is directly related with visceral manipulation and pulling the ovarian pedicle. / FAPESP: 2012/25061-0