Department of Orthopaedic Surgery (C.J.D. and C.A.G.), Division of Public Health Services, Department of Surgery (C.J.D.), and Division of General Medical Sciences (A.L.A. and J.M.D.), Washington University School of Medicine, St. Louis, Missouri.
Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.
J Bone Joint Surg Am. 2018 Dec 5;100(23):e148. doi: 10.2106/JBJS.17.00654.
Overlapping surgery is attracting increased scrutiny. The American College of Surgeons states that the attending surgeon must be present for all critical portions of a surgical procedure; however, critical portions of surgical procedures are not defined. We hypothesized that a Delphi panel process would measure consensus on critical portions of 3 common hand surgical procedures.
We used a Delphi process to achieve consensus on the critical portions of carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of the distal part of the radius. The panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Following an in-person discussion to finalize steps for each procedure, 2 online rounds were completed to rate steps from 1 (not critical) to 9 (extremely critical). We operationalized consensus as ≥80% of ratings within the same range: 1 to 3 (not critical), 4 to 6 (somewhat critical), and 7 to 9 (critical). Because of a lack of consensus on some steps after round 2, another in-person discussion and a third online round were conducted to rate only steps involving disagreement or somewhat critical ratings using a dichotomous scale (critical or not critical).
Following the first 2 rounds, there was consensus on 19 of 24 steps (including 3 steps being somewhat critical) and no consensus on 5 of 24 steps. At the end of round 3, there was consensus on all but 2 steps (identification of the medial antebrachial cutaneous nerve in ulnar nerve transposition and clinical assessment of joint stability in open reduction and internal fixation of the distal part of the radius), with moderate disagreement (3 compared with 7) for both.
The panel reached consensus on the designation of critical or noncritical for all steps of a carpal tunnel release, all but 1 step of an ulnar nerve transposition, and all but 1 step of open reduction and internal fixation of the distal part of the radius. The lack of consensus on whether 2 of the steps are critical leaves this determination at the discretion of the attending surgeon. The findings of our Delphi panel provide guidance to our division on which portions of the surgical procedure are critical and thus require the attending surgeon's presence.
重叠手术正受到越来越多的关注。美国外科医师学院规定，主治外科医生必须出现在手术的所有关键部分；然而，手术的关键部分并未定义。我们假设德尔菲小组流程将衡量对 3 种常见手部手术关键部分的共识。
我们使用德尔菲流程来达成对腕管松解术、尺神经转位术和桡骨远端切开复位内固定术的关键部分的共识。小组成员由 10 名手部外科医生（7 名接受过 fellowship培训的外科医生和 3 名研究员）组成。在进行了一次面对面的讨论以确定每个程序的步骤后，完成了 2 轮在线评估，对从 1（非关键）到 9（极其关键）的步骤进行评分。我们将共识定义为相同范围内的评分≥80%：1 到 3（非关键）、4 到 6（有些关键）和 7 到 9（关键）。由于第 2 轮后对一些步骤缺乏共识，进行了另一次面对面讨论和第 3 轮在线评估，仅对涉及分歧或有些关键评分的步骤使用二分法（关键或非关键）进行评分。
在前 2 轮之后，24 个步骤中有 19 个步骤达成共识（包括 3 个步骤有些关键），24 个步骤中没有共识。在第 3 轮结束时，除了 2 个步骤（尺神经转位术中正中前臂皮神经的识别和桡骨远端切开复位内固定术中关节稳定性的临床评估）外，所有步骤都达成了共识，这两个步骤都有中度分歧（3 比 7）。
专家组就腕管松解术的所有步骤、尺神经转位术的所有步骤（除了 1 个步骤）以及桡骨远端切开复位内固定术的所有步骤（除了 1 个步骤）的关键或非关键指定达成了共识。对 2 个步骤是否关键存在分歧，这一决定留给主治外科医生酌情决定。我们的德尔菲小组的研究结果为我们的科室提供了指导，确定了手术过程中的哪些部分是关键的，因此需要主治外科医生的参与。
