Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study

Introduction

Government and commercial healthcare payers have become increasingly concerned about surgical quality owing to evidence showing a wide range of outcomes among different surgeons and hospitals. Althugh variations in surgeon skill and perioperative care will always exist, improved methods for optimizing transparency and quality in surgery should be pursued. The potential to easily videodocument the actions of a surgeon in the operating room should make a powerful contribution to the quality of surgical care, but very little of this activity has been explored to date.

Strasberg et al. ¹ initially introduced the concept of the critical view of safety as an important technique in preventing bile duct injury when performing laparoscopic cholecystectomy. To ensure quality, documentation of the critical view of safety, through either photo or video capture, has become required practice when performing laparoscopic cholecystectomy in The Netherlands since that time.^2–4 A similar concept in quality control for laparoscopic colon surgery could be the formulation of a surgical “checklist” that defines critical operative steps and subsequent video documentation of these steps to ensure surgeon compliance. However, there are no established guidelines for this.

Usage of multimedia technology has become widespread in the medical community. Digital video documentation is increasingly being used to record operative procedures and has been claimed to improve intraoperative visualization as well as ensure accurate imaging and documentation.^5,6 However, a typical operation includes many minutes of irrelevant (e.g., cleaning the camera lens) or tedious (e.g., lengthy dissection through thick mesentery) footage that are also recorded, and filtering out only the most critical steps can be a tiresome task.

The aim of this pilot study was to evaluate the feasibility and compliance of video documentation of the key steps in laparoscopic right hemicolectomy and sigmoid colectomy using a checklist, as well as the ability to edit the recorded footage into a brief, representative video depiction of the operation.

We submitted a video related to this manuscript to Videoscopy, which we have referred to within the body of this text. This video was accepted and can be found online at http://online.liebertpub.com/doi/full/10.1089/vor.2014.0260

Materials and Methods

This study was approved by the Institutional Review Board of Weill Cornell Medical College. All archived video recordings of patients 18 years of age or older who had undergone either laparoscopic right hemicolectomy or sigmoid colectomy performed by three surgeons on the Colorectal Service at Weill Cornell Medical College/NewYork-Presbyterian Hospital from September to December 2011 were included. Twenty-four colectomies (right hemicolectomy, sigmoid colectomy) were performed during the study period. Sixteen (67%) colectomies met inclusion criteria and were included; the remaining 8 cases were excluded because of incomplete or lack of video recording. Clinical and technical variables including patient demographics, operative features, postoperative complications, and the resolution, storage, and editing data of the operative videos were collected.

Feasibility was defined as the ability to record and accurately demonstrate key surgical steps with high-quality video. Compliance was defined as demonstration of the presence of the key surgical steps and their corresponding landmarks upon review of previously recorded colectomies that were not performed according to an operative checklist defining those key steps.

Predetermined key surgical steps and corresponding anatomical landmarks

The key surgical steps and landmarks for both laparoscopic procedures were defined by expert surgeons in our department and are listed in Table 1. These are visually demonstrated with a representative video (found online at http://online.liebertpub.com/doi/full/10.1089/vor.2014.0260) and corresponding images (Figs. 1 and 2) from the examined cohort.

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FIG. 1.

Documentation of key surgical steps in right hemicolectomy. Shown are visual representations of surgical steps for right hemicolectomy: (1) exploration of the liver for metastatic lesions during colon cancer resection; (2) ileocolic pedicle identification; (3) lymphadenectomy of the ileocolic pedicle; (4) division of the right branches of the middle colic vessels; (5) medial-to-lateral dissection; (6) identification of the right ureter; (7) duodenum exposure; (8) hepatic flexure takedown; and (9) extracorporeal bowel anastomosis.

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FIG. 2.

Documentation of key surgical steps in sigmoidectomy. Shown are visual representations of surgical steps for sigmoidectomy: (1) exploration of the liver for lesions or a pyogenic abscess during sigmoidectomy for diverticulitis; (2) identification of the left ureter; (3) identification of the inferior mesenteric vessels; (4) medial-to-lateral dissection; (5) identification of hypogastric nerves; (6) splenic flexure takedown; and (7) intraoperative colonoscopy to assess anastomotic integrity.

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Table 1.

Detailed Description of the Predetermined Key Surgical Steps and Corresponding Anatomical Landmarks in Laparoscopic Colectomy

Procedure, key surgical steps	Corresponding anatomical landmarks
Laparoscopic right hemicolectomy
1. Visual exploration of intraabdominal contents, including liver, after establishing pneumoperitoneum	Liver, tumor/lesion (if applicable)
2. Identification of the ileocolic pedicle with scoring of the peritoneum and vessel division	The ileocecal junction, lower border of duodenumThe inferior border of the ileocolic pedicle
3. Skeletonization/lymphadenectomy around the origin of the ileocolic vessels	The origin of the ileocolic vessels
4. Identification and division of the right branches of the middle colic vessels	The ventral side of the SMV
5. Medial-to-lateral dissection with mobilization of the ascending colon
6. Identification of the right ureter and gonadal vessels	Right ureter, right gonadal vessels (if applicable)
7. Exposure of the duodenum	Duodenum
8. Takedown of the hepatic flexure and dividing the omental attachments	The lesser sac
9. Bowel resection and anastomosis
Laparoscopic sigmoidectomy
1. Visual exploration of intraabdominal contents, including liver, after establishing pneumoperitoneum	Liver, tumor/lesion (if applicable)
2. Identification of the left ureter and gonadal vessels by retraction of the small bowel and sigmoid colon	The left ureter, the origin of the IMA
3. Identification, dissection and division of the inferior mesenteric vessels via a peritoneal incision behind the IMA	The sacral promontory, the aortoiliac axis, the hypogastric nerve trunks, the ligament of Treitz, inferior border of the pancreas
4. Medial-to-lateral dissection with mobilization and division of the sigmoid and descending colon	The plane between Toldt's fascia and the mesocolon, the left ureter, gonadal vessels
5. Identification of the hypogastric nerves with mobilization of the proximal rectum	The superior hypogastric nerves
6. Takedown of the splenic flexure	The lesser sac
7. Bowel resection, anastomosis, and assessment of the anastomosis by intraoperative colonoscopy/leak test	The colorectal anastomosis

IMA, inferior mesenteric artery; SMV, superior mesenteric vein.

Results

In total, 16 laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were captured on video from September through December 2011. Patient demographics and operative features are described in detail in Table 2.

At the conclusion of an operation, video export to an external drive was variable, depending on operation length and file size, but did not exceed 10 minutes. After the key surgical steps were identified from the original recording over approximately 15 minutes, the median time to produce an edited video clip was 29 (range, 21–42) minutes. Thus, the overall editing and video production process was performed in close to an hour. The recorded and edited video clips had a resolution of 1440 × 1080 pixels. The edited video had a median storage volume of 659 (range, 320–1010) MB with a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds–5 minutes 38 seconds). Video capturing and editing results are described in Table 3.

Full compliance to the key surgical steps in both laparoscopic procedures was achieved in the majority of patients. Laparoscopic right hemicolectomy and sigmoid colectomy compliance ranged from 42.9% to 100% and from 77.8% to 100%, respectively. The online video (http://online.liebertpub.com/doi/full/10.1089/vor.2014.0260) demonstrates representative video clips of compliant surgical steps with corresponding still images seen in Figures 1 and 2. The surgical checklist used by reviewers summarizes these results in detail in Table 4.

Discussion

Several international large, multicenter trials have shown outcomes following a laparoscopic approach to be technically as well as oncologically equivalent to conventional open colectomy,^7–10 and adoption of laparoscopic colectomy for the treatment of various colonic diseases has increased in the past decade. In addition to the reported advantages of laparoscopy, accompanying video recording systems enable surgeons to record their operations in great detail and high resolution. However, the ability to capture intraoperative details in an era of increasing medical transparency and documentation requirements is underutilized by surgeons. In this study, we found that recording the key steps during laparoscopic colon surgery can be readily achieved in HD and edited into a brief video that highlights these important steps.

By providing high-quality imaging as well as a magnified view of the anatomical details in the operative field, video capture using a standard laparoscopic camera should be regarded as a valuable piece of documentation that can reliably record what has been performed by the surgeon during an operation.^11,12 It enables surgeons to better inform their patients, to accurately share experiences with their colleagues, and to train medical students, residents, other surgeons, and the surgical team more efficiently. ² Two groups have recently published standardized techniques for rectal surgery, concluding that operative standardization may lead to an improvement in the quality of patient care.^13,14 It is equally plausible that standardized video documentation portraying the key surgical steps in laparoscopic colon surgery will also lead to an improvement in the quality of patient care along with enhancing surgical training.

The video management system used in this study to document the operations had its own software, facilitating the video capture process, and could be readily started and stopped on the control panel. All operations were recorded for the full duration of each case, reducing potential bias by preventing the surgeon from selectively including or excluding specific operative portions. Video clips could be recorded directly into a digital format or converted easily into a different format without loss of quality. All of the recorded and edited videos in our study had a high resolution of 1440 × 1080 pixels, and with the introduction of large-capacity and high-speed hard disk and portable hard drives, video storage is no longer an impediment to documentation. ³ Fast processors and contemporary editing software allowed us to easily edit the recorded video clips. Although an optimal video management system would permit instantaneous video/audio editing to streamline synoptic surgical video production, we showed that one can document the key moments of an operation in a stepwise way.

Our study is one of the very few attempting to describe the feasibility and compliance of video documentation to capture the standardized steps of laparoscopic colon surgery. Standardization of this video documentation process using a checklist could have several important implications. The education of surgical residents and medical students could be enhanced if they are able to preoperatively review a video depicting the key operative steps and subsequently participate in the same surgical procedure. ² The video may also help refine the surgeons' operative technique and improve performance through reflective analysis. ¹⁵ Surgical video need not only serve as objective documentation of what occurred in the operating room, in addition to the subjective, traditional operative note. ¹⁶ Video can help communicate with other physicians regarding the patients' anatomical changes and surgical outcome, thereby improving patient care and aiding in planning further intervention in the multidisciplinary setting.^16–18 Increasing importance is being placed upon communication and education in the patient–physician relationship, which can be enhanced by showing the patient representative footage from his or her operation.

We believe that standardization and routine use of operative video documentation may also lead to improvements in the quality of patient care through qualitative and quantitative analyses. A recent example of this was seen in a study by Birkmeyer et al., ¹⁹ who examined the correlation between technical skill and postoperative outcomes using a representative operative videotape of surgeons performing a laparoscopic gastric bypass. A surgeon's technical skill was evaluated using this video, and the study findings suggested that greater skill was associated with decreased postoperative complications, reoperation, re-admission, and mortality. ¹⁹ It is also possible that increased attention by the surgeon at highlighted critical steps using video documentation may foster better patient care as was evidenced by Rex et al., ²⁰ who attributed significantly improved colonoscopy performance to physician awareness of procedural video recording (the Hawthorne effect).

The primary goal of our study was to examine the feasibility of capturing the key steps in laparoscopic colectomy on video and produce a brief representative video depiction of the operation, but we would like to acknowledge several issues that may limit integration of routine video documentation into surgical practice. In our study, operating rooms were fully equipped with modern recording equipment and staffed with a surgical team familiar with operative video recording. We recognize that the costs of video equipment, operative capture, and data maintenance may be high for some hospitals and providers. This requires further careful investigation to determine expected time and resource expenditure. However, it is plausible that insurers would reimburse video capture costs if it can be demonstrated to improve surgical quality and patient outcomes. The hospital would likely then store and secure the full-length video data against alteration within the existing electronic medical record.

Video editing was performed in our study in a relatively short, although not negligible, time. Despite the ability of a short representative video to facilitate communication of operative findings, routine editing of all operations is not feasible for many practitioners as each video may require nearly an hour of production time. Thus, synoptic video editing will likely remain an adjunctive tool for surgeons and educators until live intraoperative editing programs become more available and therefore only a minor component in the drive for surgical quality in its current structure.

However, it is the standardization of an operation (e.g., through the use of stepwise checklists) not just within a hospital, but between many hospitals and surgeons, coupled with video documentation that provides the greatest opportunity to improve patient care and outcomes.

In conclusion, it appears that the majority of steps in laparoscopic right hemicolectomy and sigmoid colectomy can be documented following a checklist and using a standard video management system. These key steps may then be presented in a short representative video of an operation if desired by the surgeon or educator. The high-resolution video images obtained allowed for demonstration of the key components of an operation that may help improve the quality of care in patients undergoing laparoscopic colon surgery. Prospective studies are needed to demonstrate that standardization of the critical steps in an operation and their documentation can lead to an improvement in surgical quality.