Video Analysis of Surgery: Defining the Data Set of the Future

Oliver A Varban, MD, FACS1, Adam Niemann, BS2, Jon Schram, MD3, Arthur M Carlin, MD, FACS4, Steven C Poplawski, MD, FACS5, Justin B Dimick, MD, MPH, FACS1. 1University of Michigan Health System, 2University of Michigan School of Medicine, 3Spectrum Health Medical Group, MI, 4Wayne State University, Henry Ford Health System, 5Forest Health Medical Center

Background: It has been shown that variations in surgical outcomes can be correlated directly to video based peer-rated evaluation of surgical skill. However, little is known about the use of surgical videos to identify variations in operative technique and how they may affect outcomes.

Methods: Representative videos of laparoscopic sleeve gastrectomy were voluntarily submitted by 20 surgeons who participate in the Michigan Bariatric Surgery Collaborative, a statewide consortium that uses a clinical data registry for quality improvement. Each video was devoid of patient identifiers and edited so as to exclude port placement, tissue extraction and camera exchanges. Time to completion of each step was assessed as well as variations in the tasks performed during each step. 

Results: Twenty-two videos of laparoscopic sleeve gastrectomy were submitted and 11 included  concurrent hiatal hernia repair. Data obtained from video identified variation in time to completion of each step of the procedure as well as differences in management of hiatal hernias, stapling technique and management of staple line. Mean time to completion for unedited videos was 47 minutes without hiatal hernia repair (range 28-66 minutes) and 55 minutes with hiatal hernia repair (range 34-80 minutes). Among cases involving hiatal hernia repair, 55% performed a posterior cruropexy, 27% performed an anterior cruropexy and 18% performed both. Two different vendors and 10 different permutations of staple heights and buttressing material was used during division of the stomach. The median number of staple cartridges used was 6 (range 4-7). Management of the staple line included: use of buttressing (64%), fibrin sealant (36%), oversewing (9%), use of surgical clips (18%), imbrication of the staple line (36%) and omentoplasty (55%). A leak test was performed in 50% of cases and endoscopy was performed in 17% of cases. Drains were placed 9% of the time.

Conclusions: Video analysis of laparoscopic sleeve gastrectomy provides a unique dataset that highlights variation in: 1) time to completion of each step of the procedure, 2) variation in hiatal hernia repair, 3) variation in stapling technique and 4) variation in staple line management. Video-based data of technique can be further augmented with peer-reviewed assessment of skill and also combined with a clinical outcomes registry for a robust comparative analysis on the effect of specific techniques, devices and skill on outcomes, cost and quality.

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