Goossens, R.H.M.

Differences Between Attendings' and Residents' Operative Notes for Laparoscopic Cholecystectomy (Article)

2013-04-22T00:00:00Z

Background: Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents. Methods: Attendings and residents were sent a DVD with footage of three LCs and were asked to "write" the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure ("item described" or "item not described"). Fisher's exact tests were performed using SPSS 16.0 for Mac. Results: Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings' notes and 25 items (56 %) were included more often in the residents' notes. Overall, residents significantly more often described the location of the epigastric trocar (P = 0.018), the size of both working trocars (P = 0.019), the opening of the peritoneal envelope (P = 0.002), Critical View of Safety reached (P = 0.002), and the location for removing the gallbladder (P = 0.019). With the exception of "gallbladder perforation" (20 of 21 notes), complications were underreported. Conclusions: In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents.

Grasping soft tissue by means of vacuum technique (Article)

2011-12-26T00:00:00Z

Introduction: A notable characteristic of bariatric surgery is the frequent manipulation of the bowel. The bowel is large, delicate, flexible, and has a natural lubricant on the tissue surface. Therefore the bowel is difficult to grasp and manipulate. Vacuum technique is commonly used in industry for all types of grasping and manipulation. Two types of nozzles that differed slightly in geometry (NT1 and NT2), were reviewed in an experimental set up for pull tests on pig bowels. Materials and methods: An experimental set-up was used to conduct a series of pull tests on pig bowel tissue. The basic principle of the measurements was a Newton's force balance; FPmax= Δp × A. Student t-tests, two-way ANOVA and Wilcoxon signed rank tests were conducted for the statistical analysis of NT1 and NT2 with regard to the maximum pull force (FPmax). Results: Concerning NT1 the Newton's force balance could not be confirmed. Concerning NT2 the Newton's force balance could partly be confirmed. For both nozzle types the effect of Δp on FPmaxwas significant. FPmaxincreases linear in proportion as Δp increases. This relation between FPmaxand Δp was confirmed by the Newton's force balance. Discussion: The results confirm that vacuum technique can be used as a grasp technique for soft organs, particularly the bowels. By means of a clever design of the nozzle a firm grip can be obtained on the bowel segments. Therefore vacuum technique should be studied for further development of instruments, graspers and retractors, to be used in the abdominal area.

Evaluation of a new surgical light source for difficult visibility procedures (Article)

2011-09-01T00:00:00Z

A new lighting device for open surgery of difficult access wounds was designed: the Extender add-on. The performance of the Extender is evaluated and compared with the conventional solutions used in the operating room (OR) on illumination quality. A cylindrical setup was built to measure the distribution of light in a simulated pelvic wound. The light was provided by a head-mounted light, an OR light, and a pair of Extender prototypes. The results showed that the Extender prototypes provided 12.2 lumens inside the wound, whereas the head-mounted light gave 5.7 lumens. The Extenders provided smoothly angular distributed light from 0° to 180°, whereas the head-mounted light and OR light only provided light from 115° to 180°. The Extender prototypes had a promising performance in terms of light distribution. It is expected that a more accurately produced Extender will increase performance in terms of illumination quantity and illumination distribution smoothness even further.

Operative notes do not reflect reality in laparoscopic cholecystectomy (Article)

2011-06-03T00:00:00Z

Background: Operative notes represent an essential element in safe patient care and should therefore be clear and accurate. This comparative study examined whether operative notes accurately represented the laparoscopic cholecystectomy (LC) as performed. Methods: Nine Dutch teaching and non-teaching hospitals were invited to record 20 successive LCs each and to collect the corresponding operative notes. The main outcome measures were overall differences and correspondence between video recordings and notes based on the Dutch guideline for LC and the occurrence of iatrogenic gallbladder perforation. A comparison was made of the cumulative results of recordings and operative notes, and individual recordings were compared with the corresponding notes. Results: Seven hospitals participated in the study; 125 video recordings and operative notes were fully analysed. Recordings showed more steps of the procedure than did notes. Individual comparisons showed significant differences (P≤0·001) between the recording and the corresponding note for the steps 'Introducing trocars under vision', 'Condition of the gallbladder', 'Critical view of safety' and 'Removing first and second trocar under vision'. Iatrogenic gallbladder perforation with spilled bile occurred in 31 patients (24·8 per cent), and was both recorded and reported in 29 patients. Iatrogenic gallbladder perforation with spilled bile and spilled stones occurred in 15 patients (12·0 per cent), and was recorded and reported in 11 patients. Conclusion: Operative notes do not adequately represent the actual LCs performed as they describe fewer important procedural steps. It is suggested that operative notes should include video recordings.

Design for (every)one: Co-creation as a bridge between universal design and rehabilitation engineering (Article)

2011-06-01T00:00:00Z

Design for (every)one is a macro framework that attempts to identify, share and use 'hidden solutions' in community-based rehabilitation contexts and translate them into disruptive assistive devices built with local resources or appropriate technology. Within healthcare contexts, local solutions are frequently more effective as they reflect the physical, emotional and cognitive needs of specific patients and engage all stakeholders in a specific local context. By using open horizontal innovation networks, where assistive devices can be easily shared and physically hacked by other allied health professionals, general patterns can be detected and translated into standard universal design objects. This generative design thinking approach is more than feasible with digital trends such as crowd sourcing, user-generated content and peer production. Cheap and powerful prototyping tools have become easier to use by non-engineers; it turns them into users as well as self-manufacturers of their personal assistive artefacts. This paper discusses the different aspects of this open innovation process within a 'design for disability' context and suggests the first steps in an iterative co-design methodology that brings together expertise from professional designers, occupational therapists, patients and other stakeholders. The overall aim is to gain more insights into designing qualitative occupational experiences for disabled users.

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members (Article)

2011-04-01T00:00:00Z

Objective: To assess surgical team members' differences in perception of non-technical skills. Design: Questionnaire design. Setting: Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands. Participants: Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists. Methods: All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT. Results: Ratings for 'communication' were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for 'teamwork' differed significantly between all team members (P ≤ 0.005). Within 'situation awareness' significant differences were mainly observed for 'gathering information' between surgeons and other team members (P<0.001). Finally, 72-90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate. Conclusions: This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.

Noninvasive assessment of intra-abdominal pressure by measurement of abdominal wall tension 1 (Article)

2010-05-07T00:00:00Z

Background: Sustained increased intra-abdominal pressure (IAP) has negative effects. Noninvasive IAP measurement could be beneficial to improve monitoring of patients at risk and in whom IAP measurements might be unreliable. We assessed the relation between IAP and abdominal wall tension (AWT) in vitro and in vivo. Materials and methods: The abdomens of 14 corpses were insufflated with air. IAP was measured at intervals up to 20 mm Hg. At each interval, AWT was measured five times at six points. In 42 volunteers, AWT was measured at five points in supine, sitting, and standing positions during various respiratory manoeuvres. Series were repeated in 14 volunteers to measure reproducibility by calculating coefficients of variation (CV). ANOVA was used for analyses. Results: In corpses, all points showed significant correlations between IAP and AWT (P < 0.001 for points 1-4 in the upper abdomen, P = 0.017 for point 5 and P = 0.008 for point 6 in the lower abdomen). Mean slopes were greatest at points across the epigastric region (points 1-3). In vivo measurements showed that AWT was on average 31% higher in men compared to women (P < 0.001), and increased from expiration to inspiration to Valsalva's manoeuvre (all P < 0.001). AWT was highest at points 1 and 2 and in standing position, followed by supine and sitting positions. BMI did not influence AWT. Mean CV of repeated measurements was 14%. Conclusions: AWT reflects IAP. The epigastric region appears most suitable for AWT measurements. Further longitudinal clinical studies are needed to assess usefulness of AWT measurements for monitoring of IAP.

Measurements of the Exerted Pressure by Pelvic Circumferential Compression Devices (Article)

2010-01-01T00:00:00Z

Data on the efficacy and safety of non-invasive Pelvic Circumferential Compression Devices (PCCDs) is limited. Tissue damage may occur if a continuous pressure on the skin exceeding 9.3 kPa is sustained for more than two or three hours. The aim of this study was to gain insight into the pressure build-up at the interface, by measuring the PCCD-induced pressure when applying pulling forces to three different PCCDs (Pelvic Binder((R)) , SAM-Sling ((R)) and T-POD((R)) ) in a simplified model. The resulting exerted pressures were measured at four 'anatomical' locations (right, left, posterior and anterior) in a model using a pressure measurement system consisting of pressure cuffs. The exerted pressure varied substantially between the locations as well as between the PCCDs. Maximum pressures ranged from 18.9-23.3 kPa and from 19.2-27.5 kPa at the right location and left location, respectively. Pressures at the posterior location stayed below 18 kPa. At the anterior location pressures varied markedly between the different PCCDs. The circumferential compression by the different PCCDs showed high pressures measured at the four locations using a simplified model. Difference in design and functional characteristics of the PCCDs resulted in different pressure build-up at the four locations. When following the manufacturer's instructions, the exerted pressure of all three PCCDs tested exceeded the tissue damaging level (9.3 kPa). In case of prolonged use in a clinical situation this might put patients at risk for developing tissue damage.

Non-invasive measurement of intra-abdominal pressure: A preliminary study (Article)

2008-08-01T00:00:00Z

The importance of measuring intra-abdominal pressure (IAP) has increased since the negative effects of sustained increased IAP, also known as intra-abdominal hypertension (IAH), have become known. The relation between IAP and abdominal wall tension has been included in several reports. We have developed a device to measure abdominal wall tension by measuring force and distance. This device enables us to investigate the correlation between the abdominal wall tension and IAP. The abdomens of two corpses (one female, one male) were insufflated with air. IAP was increased and measured at intervals by means of a laparoscopic set-up. Abdominal tension was measured at seven points on the abdominal wall at each interval. Pearson's correlation coefficients were used to determine the relationship between IAP and tension for each point measured. ANOVA was used to assess relations between measured tensions versus applied pressure, locations and subjects. In both corpses, all points showed significant (p < 0.001) correlations between IAP and abdominal wall tension. The points along the mid transverse plane appear to be more similar compared to more cranial and caudal points. We have assessed the feasibility of a device that non-invasively can track changes in IAP. Measurements performed with the device are preliminary results, and further investigation is needed.

Evaluation of protocol uniformity concerning laparoscopic cholecystectomy in The Netherlands (Article)

2008-04-01T00:00:00Z

Background: Iatrogenic bile duct injury remains a current complication of laparoscopic cholecystectomy. One uniform and standardized protocol, based on the "critical view of safety" concept of Strasberg, should reduce the incidence of this complication. Furthermore, owing to the rapid development of minimally invasive surgery, technicians are becoming more frequently involved. To improve communication between the operating team and technicians, standardized actions should also be defined. The aim of this study was to compare existing protocols for laparoscopic cholecystectomy from various Dutch hospitals. Methods: Fifteen Dutch hospitals were contacted for evaluation of their protocols for laparoscopic cholecystectomy. All evaluated protocols were divided into six steps and were compared accordingly. Results: In total, 13 hospitals responded-5 academic hospitals, 5 teaching hospitals, 3 community hospitals-of which 10 protocols were usable for comparison. Concerning the trocar positions, only minor differences were found. The concept of "critical view of safety" was represented in just one protocol. Furthermore, the order of clipping and cutting the cystic artery and duct differed. Descriptions of instruments and apparatus were also inconsistent. Conclusions: Present protocols differ too much to define a universal procedure among surgeons in The Netherlands. The authors propose one (inter)national standardized protocol, including standardized actions. This uniform standardized protocol has to be officially released and recommended by national scientific associations (e.g., the Dutch Society of Surgery) or international societies (e.g., European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons). The aim is to improve patient safety and professional communication, which are necessary for new developments.

Evaluation of operative notes concerning laparoscopic cholecystectomy: Are standards being met? (Article)

2007-05-01T00:00:00Z

Background Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon's operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC. Methods Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the "not described" items were performed. Results All hospitals participated. Most notes complied with the Dutch guideline (52-69%); 19-30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient's posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines. Conclusions Operative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.

Free shoulder space requirements in the design of high backrests (Article)

2003-04-15T00:00:00Z

The objective of this study was to determine the influence of scapular support on the effects of lumbar support and to prove that a high and straight backrest is inappropriate. In literature the importance of a lumbar support is noted, although data about optimal dimensions is an under-researched topic and in earlier studies on force distribution and muscle activity the backrest had a fixed form. The lumbar support is needed to maintain the lumbar lordosis but no studies deal with the question of the precise dimensions of the backrest at shoulder level. With a specially designed apparatus, forces on shoulder and seat were measured separately, and the force on the pelvis calculated, while varying seat and backrest inclination within the range from 0° to 17°. Seat-to-backrest angle (at the level of lumbar support) was kept constant at 90°. The distance between the tangent to the lumbar support and the parallel tangent to the scapular support was varied from 0, 2, 4, 6 and 8 cm. This distance is called the free shoulder space. Electromyography was measured at the erector spinae at the levels of the L1, T8 and T5 vertebrae. For all seat angles, a free shoulder space of d = 0 cm resulted in the highest back muscle activity. In agreement with the biomechanical model, EMG activity reduced with an increase of seat tilt and increase of free shoulder space. With increasing free shoulder space, a larger part of the total backrest force was carried by the lumbar support. This study shows that a high and straight backrest overrules lumbar support. Offering free shoulder space of at least 6 cm reduces back muscle activity and allows for lumbar support.

Design criteria for the reduction of shear forces in beds and seats (Article)

1995-02-01T00:00:00Z

Both with respect to the aspect of pressure sores and of comfort, the inclination of backrest and seat are, amongst other factors, important design criteria. In this study the combination of seat and backrest inclination which reduces shear forces on the seat in passive seating forms the centre of attention. A biomechanical model was developed to predict these combinations and a new measurement apparatus was used for verification of the model on 10 healthy subjects (age 24.4 S.D. 2.1 yr, height 1.77 S.D. 0.08 m, mass 66.3 S.D. 11 Kg). For chairs it was found that when little shear is accepted, a fixed inclination between seat and backrest can be chosen between 90° and 95°. For beds a parabolic relationship was found between seat and backrest inclination with a maximum seat inclination of 20° at a backrest inclination of 50°. When lying with the knees bent to a position with equal inclination of thighs and shanks, the model predicts a shear force on the seat that shoves the person into the bed for every combination of seat and backrest inclination.Both with respect to the aspect of pressure sores and of comfort, the inclination of backrest and seat are, amongst other factors, important design criteria. In this study the combination of seat and backrest inclination which reduces shear forces on the seat in passive seating forms the centre of attention. A biomechanical model was developed to predict these combinations and a new measurement apparatus was used for verification of the model on 10 healthy subjects (age 24.4 S.D 2.1 yr, height 1.77 S.D. 0.08 m, mass 66.3 S.D. 11 Kg). For chairs it was found that when little shear is accepted, a fixed inclination between seat and backrest can be chosen between 90° and 95°. For beds a parabolic relationship was found between seat and backrest inclination with a maximum seat inclination of 20° at a backrest inclination of 50°. When lying with the knees bent to a position with equal inclination of thighs and shanks, the model predicts a shear force on the seat that shoves the person into the bed for every combination of seat and backrest inclination.

Biomechanics of body support : a study of load distribution, shear, decubitus risk and form of the spine (Doctoral Thesis)

1994-02-09T00:00:00Z