Our reviewer took two products for gynecologic surgeons for a test drive. Here's what he found.
Dr. Greenberg is Chief, Division of Gynecology, Brigham & Women’s Faulkner Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts.
According to the Greek writer Pausanias, the motto “know thyself” was inscribed in the forecourt of the Temple of Apollo at Delphi. Without getting overly spiritual, this ancient dictum can be an excellent starting point for surgeons who want (or need) to improve their technique. But how do surgeons gain insight into their technical failings to best understand where they need improvement? One simple way is to ask colleagues for constructive criticism. While this approach is easy enough in theory, the perils and pitfalls when seeking meaningful change are obvious.
Recording videos of cases and personally reviewing them with a critical eye is another option that is practical and has many benefits (I do it regularly and highly recommend it). However, it does introduce a huge element of observer bias; specifically, techniques that each of us may consider adequate may be viewed by others as suboptimal. Finally, a combination method might be to record cases anonymously and ask skilled observers to review elements of the procedures and offer their collective opinions as feedback to the operating surgeon. Nice idea but it seems sort of a “pie-in-the-sky” solution. Well, it may be that the pie has landed in the form of “Crowd-Sourced Assessment of Technical Skills,” or C-SATS.
Based on technology developed at the University of Washington by a team of physicians, software engineers, and biostatisticians, researchers in 2013 demonstrated that, using specific criteria, a group a 500 Internet reviewers were able to score a surgeon’s technique as accurately as 10 expert surgeons.1 C-SATS uses the power of the Internet to rapidly and reproducibly have surgical videos analyzed by a wide range of reviewers with a focus on a defined sets of skills, such as tissue handling, efficiency of movement, and bimanual dexterity.
Reduced to simple terms, surgeons submit videos of procedures to C-SATS, which the company edits to highlight specific areas in which specific skills are demonstrated. Next, the clips are sent to online experts and reviewers worldwide, who anonymously evaluate them using defined and accepted assessment tools, such as GOALS and GEARS. The results are then tabulated and quantified and qualified feedback is provided to the submitting surgeon within hours.
I submitted 4 separate videos of vaginal cuff closures at laparoscopic and/or robotic total hysterectomy to C-SATS. Within 12 hours, their analyses of all 4 procedures came back. I then reviewed my videos again against my performance summary from C-SATS to see what I thought of their analysis of my skills. I was impressed (with their analysis, not my techniques). I mostly agreed with their conclusions and thought the whole exercise was an outstanding, confidential self-assessment tool that will help me improve my technique so that I can offer better care to my patients.
In his 1951 sci-fi classic, Foundation, Isaac Asimov introduced us to Hari Seldon and the “psychohistorians” who use mathematics and the psychology of populations to predict the future. As the Web increasingly connects our world of individuals into a crowd in the cloud, innovators are daily introducing technologies to harness our collective energy to efficiently offer solutions to challenges that previously were unattainable. I have never seen a similar product in this space but I have little doubt there will soon be many. C-SATS is innovation gone wild.
Crowd-sourced assessment of technical skills as a technology is new-very new-and, in theory, offers tremendous potential for helping surgeons perfect their technique. As excited as I was to try this product, the cynic in me cautions that the technology will be only as good as an individual’s willingness to accept the results and those results will be only as good as the assessment tools that are employed.
Submitting oneself to the judgment of others can be a threatening endeavor but, more often than not, improving necessitates some external analysis and feedback. In that regard, the technology introduced by C-SATS is beautiful in its efficiency and cold anonymity. It is not a panacea for inadequately trained surgeons or a perfectly validated method of assessing surgical competence but it is a really exciting start. Physicians who are not interested in improving their professional skills need to get different jobs. As I have long maintained, to expect perfection is unrealistic; to not seek perfection is unacceptable.
1. Chen C, White L, Kowalewski T, Aggarwal R, et al. Crowd-sourced assessment of technical skills: a novel method to evaluate surgical performance. J Surg Res. 2014;187:65.
Obesity is a big problem in the United States that seems to be growing. According to a recent study published in JAMA, more than one third of American adults (34.9%) qualify as obese (BMI ≥30) with 7.7% of women in their peak reproductive years (ages 20–39) categorized as obese grade 3 (BMI ≥40).1 While this issue has a myriad of health and healthcare implications, in operative obstetrics, it often presents the practical challenge of how to safely and comfortably perform a cesarean delivery with a massive pannus overhanging the intended surgical site.
With experience, many hospitals, L&D nurses, and obstetricians have developed their own MacGyver-style solutions with some combination of pads, tape, sheets, straps, and gravity. All too often, though, the final plan has relied on good old-fashioned elbow grease from the lowest person on the totem pole. For those of us unlucky enough to have sweated through this extreme retracting opportunity, Clinical Innovations now comes to the rescue with the Traxi Panniculus Retractor.
The Traxi Panniculus Retractor is a 25” x 16” latex-free, hypoallergenic sheet of adhesive-backed film. It is FDA-approved as a Class I device and sterilely packaged as a single-use product. In a nutshell, it looks like a giant piece of Telfa. According to the company, “application is quick and easy.” The idea is to manually retract the pannus, apply the lower portion of the Traxi 5 cm above the incision line, lift the pannus cephalad and secure the upper portion of the device to the upper abdomen/lower thorax and the level of the xiphoid process.
I used the Traxi for cesarean delivery on a patient with a BMI of 45 and a serious overhanging pannus. WOW! This thing really worked! Easy to apply; fully retracted the pannus. I see no obvious areas for improvement from my perspective.
As much as I love this product, I cannot give the folks at Clinical Innovations too many innovation stars because the Traxi is really just the best iteration of similar things many of us have been doing for years. That said, they did it, they got it right, and nobody else put all the pieces together in such a common-sense, straightforward fashion. So, kudos to the Traxi.
Performing safe cesarean deliveries on significantly obese patients is not to be taken lightly. These cases can be very difficult and present a variety of added dangers to both mother and baby. Having a simple, reliable, and reproducible way to mitigate some of the unique challenges a large pannus presents is essential. I think Traxi is that answer in a package.
I really, really, really hate holding back the pannus when doing cesarean deliveries. I am old and weak and invariably come away with a sore shoulder and sweat-soaked scrubs.
The Traxi Panniculus Retractor with Retentus Technology is as perfect a solution to the pannus problem as I have ever tried. This product is a winner . . . a big-time winner.
1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–814.
The views of the author are personal opinions and do not necessarily represent the views of Contemporary OB/GYN. Dr. Greenberg personally tests all of the products he reviews. He has no conflicts of interest with these products or the companies that produce them.