Minimally invasive surgical research has been carried out in three main domains.
We have developed a manual skills training system in a physical simulator, called MISTELS. This training system requires the completion of a series of tasks in a physical simulator with a system to measure performance that has been shown to be reliable and valid. This system has been widely used across North America and has been adopted by the Society of American Gastrointestinal and Endoscopic Surgeons as a component of their Fundamentals of Laparoscopic Surgery education and certification program. It is has been endorsed and co-sponsored by the American College of Surgeons.
Educational research projects include training and evaluation of manual skills, the development of a system of metrics that has been shown to be reliable and valid and the definition of competence using the manual skills system as an objective measuring tool.
We are currently evaluating the LTS2000 hybrid physical-electronic simulator, and several virtual reality based training systems, including MIST-VR, LapSim and ProMIS for their educational utility, and the validity and utility of their metrics for education and evaluation.
Ongoing 2016 projects:
- Investigating patient reported barriers preventing early mobilization after surgery
- Management of acute cholecystitis - an internal McGill University Health Centre audit
- A curriculum to teach safe use of surgical energy devices: does the addition of a simulation module improve learning and retention?
- Tracking career interests over the course of the MD program: a prospective longitudinal study
- Impact of clinical pathway adherence on outcomes after colorectal surgery within an enhanced recovery program
- Impact of pre-operative carbohydrate drink provision on attenuating peri-operative insulin resistance in major thoraco-abdominal surgery
- Management practices for acute calculous cholecystitis – a survey of McGill Department of General Surgery staff and residents regarding practice patterns
- Residents' opinion of the future of general surgery training
- Incisional hernia after midline versus transverse extraction incision for laparoscopic hemicolectomy: a pilot randomized trial
- Long term effects of becoming a living kidney donor
- A mobile device application for postoperative patient self-audit and education within an enhanced recovery program for colorectal surgery: a pilot study
- Attenuating the post-operative insulin resistance and promoting protein anabolism in patients undergoing major lung or abdominal surgery
- Measuring intra-operative decision-making: development and validation of a novel metric
- The effect of motivational orientation on performance in surgical residence
- Impact of the McGill multi-modal surgical recovery pathway on perioperative processes and outcomes
- Facilitation of early mobilization after colorectal surgery: a randomized controlled trial
- Natural oriface transluminal surgery: liver biopsy, peritoneal exploration of cholecystectomy
- What domains of health are relevant to the process of recovery after abdominal surgery? A Delphi study
- Exploring the learning process for acquiring advanced laparoscopic suturing
- A curriculum for training in surgical skills
- Per-oral endoscopic esophagomyotomy (Poem)
- Training for and introduction of per-oral endoscopic myotomy (Poem)
- Longitudinal assessment of operative performance
- Developing a patient-reported outcome (PRO) instrument to measure recovery after abdominal surgery: conceptual framework and item generation
Outcomes Research: what matters to patients and what surgeons need to know
The driving force behind surgical innovation – including MIS, enhanced recovery pathways, and new technologies to strengthen trainees’ surgical skills – is to improve patient outcomes while performing safe and effective surgery. Yet measuring the impact and effectiveness of these interventions is a complex and somewhat elusive task. It involves assessment of traditional clinical endpoints, patient-reported outcomes, costs, as well as surgical performance.
The focus of our research is to define and measure the relevant domains of surgical recovery and to investigate strategies that may enhance this process. We use both traditional clinical and audit data as well as patient-reported measures to determine the effect of introducing prehabilitation programs1 and Enhanced Recovery Perioperative Care Pathways (ERPs)2-4, as well as the cost5-7 (economic and societal) of these. These programs and pathways have been developed by a multidisciplinary team based on the best available evidence and on the needs and possibilities of our institution. Patient-level prospectively collected data is also being used to validate HRQL instruments8, 9 commonly used to measure surgical outcomes and to study the properties of these instruments when applied to a surgical population. A dedicated research assistant and a statistician maintain databases for ongoing randomized trials and cohort studies.
Our group has also led a multi-institution effort to develop a training and assessment tool – the Global Operative Assessment of Laparoscopic Skills – to evaluate proficiency in essential laparoscopic skills.10 This was then adapted specifically for inguinal and incisional hernia (GOALS-GH, GOALS-IH) and for flexible endoscopy (GAGES). We continue to be actively involved in identifying valid ways of translating skills and abilities in a simulated environment to the operating room.
The nature of our research interests fosters interdisciplinary collaboration with economists, epidemiologists, measurement specialists, as well as other health professionals, including nursing, physiotherapists, nutritionists, pain specialists, and pharmacists. It has also lead to presentations at national and international meetings, as well as numerous publications, some of which are outlined below.
- Li C, Carli F, Lee L, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surgical endoscopy 2013;27:1072-1082.
- Li C, Ferri LE, Mulder DS, et al. An enhanced recovery pathway decreases duration of stay after esophagectomy. Surgery 2012;152:606-614; discussion 614-606.
- Feldman L, Baldini, G., Lee, L., Carli, F. Enhanced Recovery Pathways: Organization of Evidence-Based, Fast Track Perioperative Care. ACS Surgery (In Press) 2013.
- Antonescu I, Baldini G, Watson D, et al. Impact of a bladder scan protocol on discharge efficiency within a care pathway for ambulatory inguinal herniorraphy. Surgical endoscopy 2013 Aug 17. [Epub ahead of print].
- Lee L, Sudarshan M, Li C, Latimer E, Fried GM, Mulder DS, Feldman LS, Ferri LE. Cost-effectiveness of minimally invasive versus open esophagectomy for esophageal cancer. Ann Surg Oncol 2013, 20(12):3732-3739.
- Lee L, Li C, Robert N, Latimer E, Carli F, Mulder DS, Fried GM, Ferri LE, Feldman LS. Economic impact of an enhanced recovery pathway for oesophagectomy. British Journal of Surgery 2013, 100(10):1326-1334.
- Lee L, Li C, Landry T, Latimer E, Carli F, Fried GM, Feldman LS. A Systematic Review of Economic Evaluations of Enhanced Recovery Pathways for Colorectal Surgery. Annals of Surgery 2013.
- Lee L, Schwartzman K, Carli F, Zavorsky GS, Li C, Charlebois P, Stein B, Liberman AS, Fried GM, Feldman LS: The association of the distance walked in 6 min with pre-operative peak oxygen consumption and complications 1 month after colorectal resection. Anaesthesia 2013, 68(8):811-816
- Lee L, Elfassy N, Li C, et al. Valuing postoperative recovery: validation of the SF-6D health-state utility. The Journal of surgical research 2013;184:108-114.
- Kurashima Y, Feldman LS, Al-Sabah S, Kaneva PA, Fried GM, Vassiliou MC. A tool for training and evaluation of laparoscopic inguinal hernia repair: the Global Operative Assessment Of Laparoscopic Skills-Groin Hernia (GOALS-GH). American journal of surgery 2011;201:54-61.
We have developed a live anesthetized animal model to study the physiology of pneumoperitoneum. Through the use of an esophageal Doppler probe we are able to continuously measure hemodynamic parameters during pneumoperitoneum and specific laparoscopic procedures. We have studied the use of this esophageal Doppler monitor to guide fluid replacement and optimize pre-load during laparoscopic donor nephrectomy. We are also utilizing echocardiography to measure filling volumes and laser Doppler flow probes to measure end organ perfusion under different conditions of preload, position and pneumoperitoneum.
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