Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

Abstract

Purpose Surgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice. Methods A mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached. Results There was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured. Conclusions Through an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed “core” steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The “optional” steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 1: The Retrosigmoid Approach

“…Each consultant surgeon reviewed the operative workflow individually -via computerised document with the definitions of phases, steps, instruments, technical errors, and adverse events as above (Table 1). Each expert was asked a series of questions via e-mail, seeking to assess the completeness and accuracy of the workflow (Supplementary Material A) 14 . Any additional suggestions were reviewed and added to the workflow matrix if in scope and not duplicate.…”

“…Any additional suggestions were reviewed and added to the workflow matrix if in scope and not duplicate. According to the Delphi technique, circulation and iterative revision of the workflow was repeated until data saturation was achieved, that is, all experts were satisfied that the operative workflow was complete and accurate 14 .…”

“…Deconstructing a complex procedure into a systematic operative workflow requires expert consensus. Existing literature has demonstrated subject experts generating comprehensive and standardised workflow framework for non-neurosurgical proceedures [11][12][13] and more recently a neurosurgical procedure 14 . The Delphi technique allows the generation of group consensus through iterative questionnaires/surveys, interspersed with feedback 13 .…”

A Standardised Protocol for Neuro-endoscopic Lavage for Post-haemorrhagic Ventricular Dilatation: A Delphi Consensus Approach

“…The benefits of generating a standardised workflow and protocol for novel procedures such as NEL are well described in the literature in applications within neurosurgery and across surgical specialties [9,[11][12][13]. Firstly, the protocol developed will provide standardisation for the development and implementation of a national randomised-controlled trial to investigate the efficacy of NEL in PHVD.…”

“…In this study, a modified Delphi consensus was conducted to standardise the inclusion criteria, operative workflow, and early post-operative care of NEL, with the aim of ensuring the procedure is delivered consistently and uniformly across centres. Similar modified Delphi methodologies have been effective in developing workflows for contemporary surgical procedures [9–15]. The work provides a platform for future trials, training, and implementation of NEL [10, 14, 15].…”