Tasks Required for a Correct Training Approach to FESS

What are the hierarchical steps required to perform successful functional endoscopic sinus surgery (FESS)?

Bottom Line:
Ten tasks and 49 subtasks required for a correct approach to completing FESS were identified based on literature review and expert consensus, offering the opportunity to improve surgical training and enhance patient safety by identifying high-risk steps in the procedure, and determining how risk can be mitigated.

Background: FESS is indicated in chronic rhinosinusitis management and has been shown to be as a reliable treatment to restore physiologic drainage and ventilation of the paranasal sinuses. Surgical simulators provide a risk-free, cost-effective environment to practice the skills required to develop proficiency in FESS. Improvements in human factors training involve tackling such areas as communication teamwork, situational awareness checklists, and error strategy management. Because errors in FESS can have significant consequences, learning by trial and error is not feasible. Highlighting the steps that require more supervision and guidance allows trainees to improve skills in a safe environment and can address the concerns in allowing trainees to perform technically challenging high-risk steps.

Study design: Literature review of published descriptions of FESS techniques, observations of three FESSes, and interviews with surgeons on FESS techniques, as well as observation of 25 FESS cases from July to October 2017.

Setting: Department of Otorhinolaryngology, Head and Neck Surgery University Hospital, Galway, Ireland; Scopus, PubMed, MEDLINE, and UpToDate databases.

Synopsis: Variations existed between surgeons’ techniques and between steps required to successfully perform FESS among patients with varying severity of disease. There were no serious adverse events during the surgeries. A task list was derived from the steps involved in performing a successful FESS. The list was then modified and edited based on consultation with a consensus group of eight surgeons and one anesthetist, all familiar with the procedure. Ten principal tasks (prepare patient; anesthesia; otolaryngologist preparation; uncinectomy; maxillary antrostomy; anterior ethmoidectomy; posterior ethmoidectomy; sphenoid osteotomy; frontal sinus work; postoperative care) and 49 subtasks were identified.

Of the potential errors at each subtask, nine scored 10 points or higher on a risk score, with the two highest subtask errors scoring 12 (lamina papyri damage/medial rectus injury) and 15 points (throat pack not removed). These two subtasks were rated “possible” on the frequency score and “major or extreme” on the severity score. Variation in practice existed within the hospital and was the most significant risk to patient safety. Other risks with extreme impact included arterial bleeds, skull base injury, and optic nerve damage.

Citation: Corbett M, O’Connor P, Byrne D, Thornton M, Keogh I. Identifying and reducing risks in functional endoscopic sinus surgery through a hierarchical task analysis. Laryngoscope Inv Otol. Published November 28, 2018. doi: 10.1002/lio2.220.