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Gani F, Cerullo M, Zhang X, Canner JK, Conca-Cheng A, Hartzman AE, Husain SG, Cirocco WC, Traugott AL, Arnold MW, Johnston FM, Pawlik TM. Effect of surgeon “experience” with laparoscopy on postoperative outcomes after colorectal surgery. Surgery 2017; 162:880-890. [DOI: 10.1016/j.surg.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/23/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
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Cui Y, Li C, Xu Z, Wang Y, Sun Y, Xu H, Li Z, Sun Y. Robot-assisted versus conventional laparoscopic operation in anus-preserving rectal cancer: a meta-analysis. Ther Clin Risk Manag 2017; 13:1247-1257. [PMID: 29026312 PMCID: PMC5626418 DOI: 10.2147/tcrm.s142758] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective The aim of this meta-analysis is to provide recommendations for clinical practice and prevention of postoperative complications, such as circumferential resection margin (CRM) involvement, and compare the amount of intraoperative bleeding, safety, operative time, recovery, outcomes, and clinical significance of robot-assisted and conventional laparoscopic procedures in anus-preserving rectal cancer. Methods A literature search (PubMed) was performed to identify biomedical research papers and abstracts of studies comparing robot-assisted and conventional laparoscopic procedures. We attempted to obtain the full-text link for papers published between 2000 and 2016, and hand-searched references for relevant literature. RevMan 5.3 software was used for the meta-analysis. Results Nine papers (949 patients) were eligible for inclusion; there were 473 patients (49.8%) in the robotic group and 476 patients (50.2%) in the laparoscopic group. According to the data provided in the literature, seven indicators were used to complete the evaluation. The results of the meta-analysis suggested that robot-assisted procedure was associated with lower intraoperative blood loss (mean difference [MD] −41.15; 95% confidence interval [CI] −77.51, −4.79; P=0.03), lower open conversion rate (risk difference [RD] −0.05; 95% CI −0.09, −0.01; P=0.02), lower hospital stay (MD −1.07; 95% CI −1.80, −0.33; P=0.005), lower overall complication rate (odds ratio 0.58; 95% CI 0.41, 0.83; P=0.003), and longer operative time (MD 33.73; 95% CI 8.48, 58.99; P=0.009) compared with conventional laparoscopy. There were no differences in the rate of CRM involvement (RD −0.02; 95% CI −0.05, 0.01; P=0.23) and days to return of bowel function (MD −0.03; 95% CI −0.40, 0.34; P=0.89). Conclusion The Da Vinci robot was superior to laparoscopy with respect to blood loss, open conversion, hospital stay, and postoperative complications during anus-preserving rectal cancer procedures; however, conventional laparoscopy had an advantage regarding operative time. The remaining indicators (CRMs and recovery from intestinal peristalsis) did not differ.
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Affiliation(s)
- Yongzhen Cui
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences
| | - Cheng Li
- Department of President's Office, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Zhongfa Xu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Shandong Academy of Medical Sciences, Jinan
| | - Yingming Wang
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences
| | - Yamei Sun
- Department of Clinical Laboratory, Zhucheng People's Hospital of Shandong Province, Zhucheng, People's Republic of China
| | - Huirong Xu
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Zengjun Li
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Yanlai Sun
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
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Robotic versus laparoscopic versus open colorectal surgery: towards defining criteria to the right choice. Surg Endosc 2017; 32:24-38. [PMID: 28812154 DOI: 10.1007/s00464-017-5796-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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The American Society of Colon and Rectal Surgeons Assessment Tool for Performance of Laparoscopic Colectomy. Dis Colon Rectum 2017; 60:738-744. [PMID: 28594724 DOI: 10.1097/dcr.0000000000000817] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement. OBJECTIVE The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation. DESIGN During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts. SETTING The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee. PATIENTS Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES Assessment tool reliability and internal consistency were measured. RESULTS From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006). LIMITATIONS The study was limited by rater bias to technique and style. CONCLUSIONS The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.
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Celentano V. Laparoscopic sigmoid resection for diverticulitis is rarely a suitable case for the initial phase of the learning curve. Int J Colorectal Dis 2017; 32:1095-1096. [PMID: 28409268 DOI: 10.1007/s00384-017-2816-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Valerio Celentano
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK.
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Meagher AP, Yang S, Li S. Is it right to ignore learning-curve patients? Laparoscopic colorectal trials. ANZ J Surg 2017. [PMID: 28640984 DOI: 10.1111/ans.14070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Increasingly complex, technically demanding surgical procedures utilizing emerging technologies have developed over recent decades and are recognized as having long 'learning curves'. This raises significant new issues. Ethically and scientifically, the outcome of a patient in the learning curve is as important as the outcome of a patient outside the learning curve. The aim of this study is to highlight just one aspect of our approach to learning-curve patients that should change. METHODS The protocols of multicentre, prospective, randomized trials of patients undergoing either traditional open or laparoscopic surgery for colorectal cancer were reviewed. The number of patients excluded from the published trial results because they were in surgeons' learning curves was calculated. The seven editorials accompanying these publications were also examined for any mention of these patients. RESULTS The eight studies identified had similar designs. All patients in the surgeons' laparoscopic learning curves, which were often several years long, were excluded from the actual trials. The total number of patients included in the trial publications was 5680. The number of patients excluded because they were in the surgeons' laparoscopic learning curves was >10 605. In none of the studies or accompanying editorials is there any mention of the total number of patients in the surgeons' learning curves, these patients' outcomes or how inclusion of their outcomes might have affected the overall results. CONCLUSION Learning curves are inescapable in modern medicine. Our recognition of patients in these curves should evolve, with more data about them included in trial publications.
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Affiliation(s)
- Alan P Meagher
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Shi Yang
- Department of Colorectal Surgery, Tianjin Union Medical Centre, Tianjin, China
| | - Shuyuan Li
- Department of Colorectal Surgery, Tianjin Union Medical Centre, Tianjin, China
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Kang BM, Park SJ, Lee KY, Lee SH. Single-Port Laparoscopic Surgery Can Be Performed Safely and Appropriately for Colon Cancer: Short-Term Results of a Pilot Randomized Controlled Trial. J Laparoendosc Adv Surg Tech A 2017; 27:501-509. [PMID: 28061037 DOI: 10.1089/lap.2016.0467] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Single-port laparoscopic surgery (SPLS) has gained popularity due to its cosmetic benefit, and therefore, has been applied to several kinds of benign operations, such as appendectomy and cholecystectomy. The safety and suitability of SPLS for colon cancer has not been widely proved. We aimed at validating the safety, efficacy, and short-term quality of life (QOL) of SPLS compared with conventional laparoscopic surgery (CLS) in patients with colon cancer. MATERIALS AND METHODS Between June 2010 and April 2011, a total of 62 patients with pathology-proven colon cancer were randomly allocated to two groups: SPLS and CLS. Data were analyzed according to the intention-to-treat principle. RESULTS In total, there were 62 patients (35 men and 27 women) with a mean age of 63.0 years (range, 38-82). The baseline characteristics of the patients and tumor factors were well balanced between two groups. The operation time and estimated blood loss were similar, whereas intraoperative complications only occurred in three patients, all of whom were in the SPLS group. Conversion to CLS or open surgery occurred in 6 (19.4%) patients of the SPLS group. The number of harvested lymph nodes and length of proximal and distal resection margins were not statistically different between two groups. Postoperative complications and recovery of bowel function were similar in both groups, but fatal postoperative complication occurred in one case in the SPLS group. The QOL between two groups was identical in all domains until postoperative 12 months. CONCLUSIONS SPLS for colon cancer is feasible and can be performed by following oncologic principles. However, surgeons should be aware of the potential for unexpected adjacent organ injury ( ClinicalTrial.gov identifier: NCT01203969).
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Affiliation(s)
- Byung Mo Kang
- 1 Department of Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine , Chuncheon, South Korea
| | - Sun Jin Park
- 2 Department of Surgery, Kyung Hee Medical Center, Kyung Hee University School of Medicine , Seoul, South Korea
| | - Kil Yeon Lee
- 2 Department of Surgery, Kyung Hee Medical Center, Kyung Hee University School of Medicine , Seoul, South Korea
| | - Suk-Hwan Lee
- 3 Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine , Seoul, South Korea
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Experience and dissection device are more relevant than patient-related factors for operation time in laparoscopic sigmoid resection-a retrospective 8-year observational study. Int J Colorectal Dis 2017; 32:1703-1710. [PMID: 28879419 PMCID: PMC5691094 DOI: 10.1007/s00384-017-2896-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical outcome is influenced by multiple patient-specific factors and operative expertise of the surgeon. Clinical relevance of medical technical innovations often remains unclear even though laparoscopic surgical procedures are characterized by continual advancement of various devices. Lately, in dissection and sealing technology, fast-cutting ultrasonic scissors are combined with simultaneous bipolar coagulation (bimodal dissection device (BDD)). We investigated how this new technology, operative expertise, and patient-specific factors (body mass index, age) influence operation time in laparoscopic-assisted sigmoid resection. METHODS Between 2008 and 2016, 161 laparoscopic sigmoid resections (52% conventional dissection device (CDD); 48% BDD) performed in a single center were retrospectively evaluated. Biometric patient data, complication rates, and surgery duration, reflecting the learning curve, were analyzed. Operations were performed by experienced surgeons (n = 3) and trainees (n = 4). RESULTS Minor postoperative complications (e.g., impaired wound healing, non-revisional secondary bleeding) occurred in 11 cases (6.8%). Major complications (e.g., bleeding requiring revision, anastomotic leakage) were observed in 3.7%. No heat-related coagulation damage was observed. BDD reduced operation time for both experienced (CDD 150 min, BDD 125 min; p < 0.001) and trainee surgeons (CDD 169 min, BDD 135 min; p = 0.036). Reduction of operation time (indicative of a learning curve in progress) was observed for all surgeons. The curve was steeper using BDD. CONCLUSIONS Patient-specific factors did not have a significant effect on operation time. Even taking the learning curve into account, a combination of ultrasonic dissection and simultaneous bipolar coagulation reduces operation time of laparoscopic-assisted sigmoid resection, regardless of surgeon's expertise.
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Surgeon Annual and Cumulative Volumes Predict Early Postoperative Outcomes after Rectal Cancer Resection. Ann Surg 2017; 265:151-157. [DOI: 10.1097/sla.0000000000001672] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Massarotti H, Rodrigues F, O'Rourke C, Chadi SA, Wexner S. Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery. Colorectal Dis 2017; 19:76-85. [PMID: 27234928 DOI: 10.1111/codi.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/16/2016] [Indexed: 12/19/2022]
Abstract
AIM The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery. METHOD An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C). RESULTS In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity. CONCLUSION Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.
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Affiliation(s)
- H Massarotti
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - F Rodrigues
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - C O'Rourke
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S A Chadi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Helewa RM, Rajaee AN, Raiche I, Williams L, Paquin-Gobeil M, Boushey RP, Moloo H. The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance. Colorectal Dis 2016; 18:1057-1062. [PMID: 26990716 DOI: 10.1111/codi.13333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 01/31/2016] [Indexed: 12/16/2022]
Abstract
AIM Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centres. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM programme. METHOD All patients who underwent TEM at the Ottawa Hospital, Ottawa, Canada, between October 2009 and September 2014 were included. Data were abstracted through a retrospective chart review. The average rate of lesion excision (ARE) was calculated to standardize the operation time by size of the pathological specimen (min/cm3 ), representing a measure of surgical efficiency. Surgical efficiency was plotted using restricted cubic splines. Predictors of higher ARE were determined using multivariable regression. RESULTS During the study period 108 patients underwent TEM. ARE was available for 95 patients of mean age 67.2 years. The mean ARE was 18.6 min/cm3 . On adjusting for important covariates, the ARE improved with each additional case until 16 cases were completed. Significant predictors of higher ARE on multivariable analysis were age < 50 years, experience of fewer than five cases, and carcinoid/gastrointestinal stromal tumour or scar histology. CONCLUSION Operative efficiency appears to improve as surgeons completed 16 TEM cases. We have identified important factors that result in longer operating time. The study has important implications with regard to surgical training and operative planning for new TEM programmes.
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Affiliation(s)
- R M Helewa
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada.
| | - A N Rajaee
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
| | - I Raiche
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
| | - L Williams
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
| | - M Paquin-Gobeil
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
| | - R P Boushey
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
| | - H Moloo
- Department of Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
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Tomassini F, Scuderi V, Colman R, Vivarelli M, Montalti R, Troisi RI. The single surgeon learning curve of laparoscopic liver resection: A continuous evolving process through stepwise difficulties. Medicine (Baltimore) 2016; 95:e5138. [PMID: 27787369 PMCID: PMC5089098 DOI: 10.1097/md.0000000000005138] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The aim of the study was to evaluate the single-surgeon learning curve (SSLC) in laparoscopic liver surgery over an 11-year period with risk-adjusted (RA) cumulative sum control chart analysis.Laparoscopic liver resection (LLR) is a challenging and highly demanding procedure. No specific data are available for defining the feasibility and reproducibility of the SSLC regarding a consistent and consecutive caseload volume over a specified time period.A total of 319 LLR performed by a single surgeon between June 2003 and May 2014 were retrospectively analyzed. A difficulty scale (DS) ranging from 1 to 10 was created to rate the technical difficulty of each LLR. The risk-adjusted cumulative sum control chart (RA-CUSUM) analysis evaluated conversion rate (CR), operative time (OT) and blood loss (BL). Perioperative morbidity and mortality were also analyzed.The RA-CUSUM analysis of the DS identified 3 different periods: P1 (n = 91 cases), with a mean DS of 3.8; P2 (cases 92-159), with a mean DS of 5.3; and P3 (cases 160-319), with a mean DS of 4.7. P2 presented the highest conversion and morbidity rates with a longer OT, whereas P3 showed the best results (P < 0.001). Fifty cases were needed to achieve a significant decrease in BL. The overall morbidity rate was 13.8%; no perioperative mortality was observed.According to our analysis, at least 160 cases (P3) are needed to complete the SSLC performing safely different types of LLR. A minimum of 50 cases can provide a significant decrease in BL. Based on these findings, a longer learning curve should be anticipated to broaden the indications for LLR.
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Affiliation(s)
- Federico Tomassini
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School
| | - Vincenzo Scuderi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School
| | - Roos Colman
- Bio Cell Statistics, Faculty of Ghent University, Belgium
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Ivan Troisi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School
- Correspondence: Roberto Ivan Troisi, Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, De Pintelaan, Ghent, Belgium (e-mail: )
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Matthews AH, Abdelrahman T, Powell AGMT, Lewis WG. Surgical Education's 100 Most Cited Articles: A Bibliometric Analysis. JOURNAL OF SURGICAL EDUCATION 2016; 73:919-929. [PMID: 27344302 DOI: 10.1016/j.jsurg.2016.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/03/2016] [Accepted: 05/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Bibliometric analysis highlights the key topics and publications, which have shaped surgical education. Here, the 100 most cited articles in the arena of surgical education were analyzed. METHODS Thomson Reuters Web of Science was interrogated using the keyword search terms "surgery" and ("learning" or "skills" or "competence" or "assessment" or "training" or "procedure-based assessments" or "performance" or "technical skills" or "curriculum" or "education" or "mentoring"] to identify all English language full articles, and the 100 most cited articles were analyzed by topic, journal, author, year, institution, and country of origin. RESULTS A total of 403,733 eligible articles were returned and the median citation number was 164 (range: 107-1018). The most cited article (by Seymour, Yale University School of Medicine, Annals of Surgery, 1018 citations) focused on the use of virtual reality surgical simulation training. Annals of Surgery published the highest number of articles and received the most citations (n = 16, 3715 citations). The countries with the greatest number of publications were the USA (n = 45), Canada (n = 19), and the UK (n = 18). The commonest topics included simulation (n = 45) and assessment of clinical competence (n = 40). CONCLUSION Surgical skill acquisition and assessment was the area of focus of 85% of the most cited contemporary articles, and this study provides the most cited references, serving as a guide as to what makes a citable published work in the field of surgical education.
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Affiliation(s)
| | - Tarig Abdelrahman
- Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | | | - Wyn G Lewis
- Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom.
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Julien M, Dove J, Quindlen K, Halm K, Shabahang M, Wild J, Blansfield J. Evolution of Laparoscopic Surgery for Colorectal Cancer: The Impact of the Clinical Outcomes of Surgical Therapy Group Trial. Am Surg 2016. [DOI: 10.1177/000313481608200825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Clinical Outcomes of Surgical Therapy Group (COST) Trial established laparoscopic procedures offer short-term benefits while preserving the same oncologic outcomes in colorectal cancer (CRC) patients compared with open procedures. The aim of this study was to evaluate the trend of laparoscopic resection for CRC before and after the publication of the COST Trial. Retrospective study of surgically treated CRC patients was conducted from January 2000 to December 2009. Surveillance, Epidemiology, and End Results Program and Medicare. Between 2000 and 2009, 147,388 patients underwent resection for CRC, 9,901 resections were performed laparoscopically. In 2000, 1.0 per cent of colorectal resections were performed laparoscopically. There was a dramatic increase in laparoscopic resections in 2009 to 30.4 per cent. During this time period, rates of laparoscopic resections increased for all tumor stages. Right colectomies and early stage tumors had the most significant rise from 3.1 per cent (2004) to 38.7 per cent (2009) and 4.41 per cent (2004) to 39.17 per cent (2009), respectively; whereas, rectal and later stage tumors resection rates were more modest from 2.1 per cent (2004) to 13.2 per cent (2009) and 1.41 per cent (2004) to 17.10 per cent (2009), respectively. This study demonstrates the COST Trial had a significant impact on utilization of laparoscopic colorectal resection for CRC. Although laparoscopic colorectal resections have been accepted for all types of CRCs, more difficult procedures are being adopted at slower rates.
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Affiliation(s)
| | - James Dove
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - Kristen Halm
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - Jeffrey Wild
- Geisinger Medical Center, Danville, Pennsylvania
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Vaccarezza H, Sahovaler A, Im V, Rossi G, Vaccaro C. Hand-assisted laparoscopic colorectal surgery with double-glove technique. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hernán Vaccarezza
- General Surgery Department, Italian Hospital of Buenos Aires; Buenos Aires City Argentina
| | - Axel Sahovaler
- General Surgery Department, Italian Hospital of Buenos Aires; Buenos Aires City Argentina
| | - Víctor Im
- General Surgery Department, Italian Hospital of Buenos Aires; Buenos Aires City Argentina
| | - Gustavo Rossi
- General Surgery Department, Italian Hospital of Buenos Aires; Buenos Aires City Argentina
| | - Carlos Vaccaro
- General Surgery Department, Italian Hospital of Buenos Aires; Buenos Aires City Argentina
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de'Angelis N, Lizzi V, Azoulay D, Brunetti F. Robotic Versus Laparoscopic Right Colectomy for Colon Cancer: Analysis of the Initial Simultaneous Learning Curve of a Surgical Fellow. J Laparoendosc Adv Surg Tech A 2016; 26:882-892. [PMID: 27454105 DOI: 10.1089/lap.2016.0321] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Robotic surgery was introduced to overcome laparoscopic drawbacks. This study aimed to compare the learning curve of robotic-assisted right colectomy (RRC) versus laparoscopic-assisted right colectomy (LRC) for colon cancer with respect to operative times and perioperative outcomes. In addition, the health-related costs associated with both procedures were analyzed and compared. METHODS Between 2012 and 2015, 30 consecutive patients underwent RRC and 50 patients LRC for colon cancer. All procedures were performed by a surgical fellow novice in minimally invasive colorectal surgery. The operative time and the cumulative sum method were used to evaluate the learning curve of RRC versus LRC. RESULTS The mean operative times were 200.5 minutes for RRC and 204.1 minutes for LRC (P = .408) and showed a significant decrease over consecutive procedures (P < .0001). The number of cases necessary to identify a drop in the operative time was 16 for RRC and 25 for LRC. RRC procedures were associated with significantly reduced blood loss (P = .012). Two patients (4%) in the LRC group were converted to laparotomy, whereas no conversion was required in the RRC group. Surgery-related costs were significantly more expensive for RRC, but when combined with the hospitalization-related costs, LRC and RRC did not differ (P = .632). CONCLUSIONS Both robotic and laparoscopic operative times decrease rapidly with practice. However, RRC is associated with a faster learning curve than LRC. The simultaneous development of these two minimally invasive approaches appears to be safe and feasible with acceptable health-related costs.
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Affiliation(s)
- Nicola de'Angelis
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Vincenzo Lizzi
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Daniel Azoulay
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Francesco Brunetti
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
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Abstract
To improve visualization during minimal access surgery, a novel robotic camera has been developed. The prototype camera is totally insertable, has 5° of freedom, and is remotely controlled. This study compared the performance of laparoscopic surgeons using both a laparoscope and the robotic camera. The MISTELS (McGill Inanimate System for the Training and Evaluation of Laparoscopic Skill) tasks were used to test six laparoscopic fellows and attending surgeons. Half the surgeons used the laparoscope first and half used the robotic camera first. Total scores from the MISTELS sessions in which the laparoscope was used were compared with the sessions in which the robotic camera was used and then analyzed with a paired t test (P< .05 was considered significant). All six surgeons tested showed no significant difference in their MISTELS task performance on the robotic camera compared with the standard laparoscopic camera. The mean MISTELS score of 963 for all subjects who used a laparoscope and camera was not significantly different than the mean score of 904 for the robotic camera (P= .17). This new robotic camera prototype allows for equivalent performance on a validated laparoscopic assessment tool when compared with performance using a standard laparoscope.
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Affiliation(s)
- Vivian E M Strong
- Department of Surgery, Gastric and Mixed Tumor, Memorial Sloan Kettering Cancer, New York, NY 10032, USA
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Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume. Dis Colon Rectum 2016; 59:535-42. [PMID: 27145311 DOI: 10.1097/dcr.0000000000000580] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown. OBJECTIVE The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time. DESIGN This was a retrospective study. SETTINGS This study was conducted in a tertiary referral hospital. PATIENTS Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status. MAIN OUTCOME MEASURES In-hospital mortality and postoperative complications of surgery were measured. RESULTS A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic). LIMITATIONS This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting. CONCLUSIONS Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.
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Brown KM, Geller DA. What is the Learning Curve for Laparoscopic Major Hepatectomy? J Gastrointest Surg 2016; 20:1065-71. [PMID: 26956007 DOI: 10.1007/s11605-016-3100-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 02/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50-65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC). METHODS We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments. RESULTS Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45-60 cases is evident for laparoscopic hepatic resection. CONCLUSION Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45-60 cases.
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Affiliation(s)
- Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - David A Geller
- Liver Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA. .,UPMC Liver Cancer Center, UPMC Montefiore, 3459 Fifth Ave, 7 South, Pittsburgh, PA, 15213-2582, USA.
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Trudeau MO, Swaroop M, Rothstein DH. Humanitarian skill set acquisition trends among graduating US surgical residents, 2004-2014. J Surg Res 2016; 203:319-23. [PMID: 27363639 DOI: 10.1016/j.jss.2016.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/21/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although interest in practicing surgery in resource-constrained settings is on the rise among graduating US surgical residents, there is ongoing debate about an optimal humanitarian skill set for surgeons who chose to work in such settings. In addition, increased emphasis on general surgery case exposure at the cost of specialty surgery case exposure has been documented and may have a negative impact on the breadth of resident training. Review of general surgery resident case logs to gauge experience in specialty surgery may provide insight into residents' readiness for work in resource-limited settings. METHODS We compared Accreditation Council for Graduate Medical Education general surgery resident case logs from 2004 to 2014 for operations thought to be essential for working in resource-constrained settings. These operations were chosen from published literature on this topic and authors' personal experience. Case numbers for specialty operations were compared by unpaired t-test analysis between the two periods. RESULTS Case averages in pediatric, genitourinary, and gynecologic surgery decreased significantly from 2004 to 2014 (range, 27%-46%). Orthopedic surgery case averages were unchanged, and plastic and general abdominal surgery case averages increased (range, 47%-50%). CONCLUSIONS Case mix among graduating US surgical residents has narrowed over the past 10 y. Resident experience in a variety of specialty fields, thought to be essential in resource-constrained settings, decreased markedly over the study period. Residents who intend to work in resource-constrained settings may need to craft individualized residency experiences or pursue postgraduate training in specialty surgery courses to best prepare for such work.
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Affiliation(s)
| | - Mamta Swaroop
- Trauma and Critical Care Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - David H Rothstein
- Department of Pediatric Surgery, Women & Children's Hospital of Buffalo, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, SUNY, Buffalo, New York.
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Toledano Trincado M, Sánchez Gonzalez J, Blanco Antona F, Martín Esteban ML, Colao García L, Cuevas Gonzalez J, Mayo Iscar A, Blanco Alvarez JI, Martín del Olmo JC. How to reduce the laparoscopic colorectal learning curve. JSLS 2016; 18:JSLS-D-13-00321. [PMID: 25392640 PMCID: PMC4154430 DOI: 10.4293/jsls.2014.00321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve. Methodology: From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes. Results: Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70. Conclusions: The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12. What is new in this paper? The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.
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Affiliation(s)
| | | | | | | | - Laura Colao García
- Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain
| | | | - Agustin Mayo Iscar
- Department of Statistics and Operational Research, University of Valladolid, Spain
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72
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Abstract
BACKGROUND Laparoscopic colectomy has a shorter length of stay and less analgesic requirements than its open counterpart. Studies have suggested a learning curve of 30 cases. It is uncertain whether surgeons in rural settings have the case volume to acquire and maintain the necessary skill set. The aim of this study was to analyze the volume of colon resections performed by surgeons in rural practice. METHODS We performed a retrospective cohort study of the laparoscopic and open partial colectomy case volumes of rural general surgeons seeking American Board of Surgery recertification in 2012. Results were stratified by large and small rural area. RESULTS One hundred ninety-seven surgeons were classified as practicing in a rural setting (large rural-150, small rural-47). The median open partial colectomy frequency for large rural surgeons was 7 cases and 4 for small rural surgeons. Median annual partial laparoscopic colectomy volume was 1.0 for large rural surgeons and 0.0 for small rural surgeons. Approximately half of surgeons in both groups did not perform a laparoscopic partial colectomy. CONCLUSIONS Industry and financial pressures to promote laparoscopic colectomy may not promote optimal patient outcomes in rural settings, as safety concerns may outweigh the modest benefits of the procedure. Although referral to remote high-volume centers could be advocated, the need for rural general surgeons to perform urgent colectomy for acute indications and the desire of many patients to have care close to home must also be considered.
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73
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Increased Caseload Volume is Associated With Better Oncologic Outcomes After Laparoscopic Resections for Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:49-53. [DOI: 10.1097/sle.0000000000000221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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74
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Tsai KY, Kiu KT, Huang MT, Wu CH, Chang TC. The learning curve for laparoscopic colectomy in colorectal cancer at a new regional hospital. Asian J Surg 2016; 39:34-40. [DOI: 10.1016/j.asjsur.2015.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 02/12/2015] [Accepted: 03/12/2015] [Indexed: 02/07/2023] Open
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Keller DS, Delaney CP, Hashemi L, Haas EM. A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery. Surg Endosc 2015; 30:4220-8. [PMID: 26715021 DOI: 10.1007/s00464-015-4732-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. METHODS The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. RESULTS A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group. CONCLUSIONS Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.
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Affiliation(s)
- Deborah S Keller
- Colorectal Surgical Associates, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA. .,Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
| | - Conor P Delaney
- University Hospitals-Case Medical Center, Cleveland, OH, USA
| | - Lobat Hashemi
- Healthcare Outcomes and Research, Covidien, Mansfield, MA, USA
| | - Eric M Haas
- Colorectal Surgical Associates, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.,Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
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76
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Laparoscopic sigmoid colectomy: Are all laparoscopic techniques created equal? Surg Endosc 2015; 30:3567-72. [DOI: 10.1007/s00464-015-4654-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/28/2015] [Indexed: 11/26/2022]
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77
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A multi-modal approach to training in laparoscopic colorectal surgery accelerates proficiency gain. Surg Endosc 2015; 30:3007-13. [DOI: 10.1007/s00464-015-4591-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/19/2015] [Indexed: 02/06/2023]
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78
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Valinluck Lao V, Steele SR. The role of simulation in colon and rectal surgery training. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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79
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Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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80
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Hamdan MF, Day A, Millar J, Carter FJC, Coleman MG, Francis NK. Outreach training model for accredited colorectal specialists in laparoscopic colorectal surgery: feasibility and evaluation of challenges. Colorectal Dis 2015; 17:635-41. [PMID: 25580874 DOI: 10.1111/codi.12892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/12/2014] [Indexed: 12/15/2022]
Abstract
AIM The aim of this study was to explore the feasibility and safety of an outreach model of laparoscopic colorectal training of accredited specialists in advanced laparoscopic techniques and to explore the challenges of this model from the perspective of a National Training Programme (NTP) trainer. METHOD Prospective data were collected for unselected laparoscopic colorectal training procedures performed by five laparoscopic colorectal NTP trainees supervised by a single NTP trainer with an outreach model between 2009 and 2012. The operative and postoperative outcomes were compared with standard laparoscopic colorectal training procedures performed by six senior colorectal trainees under the supervision of the same NTP trainer within the same study period. The primary outcome was 30-day mortality. The Mann-Whitney test was used to compare continuous variables and the Chi squared or Fisher's exact tests were applied for the analysis of categorical variables. The level of statistical significance was set at P < 0.05. RESULTS During the study period 179 elective laparoscopic colorectal procedures were performed. This included 54 cases performed by NTP trainees and 125 cases performed by the supervised trainees. There were no significant differences in age, gender, body mass index, American Society of Anesthesiologists grade, pathology and procedure type between both groups. Seventy-eight per cent of the patients operated on by the NTP trainees had had no previous abdominal surgery, compared with 50% in the supervised trainees' group (P = 0.0005). There were no significant differences in 30-day mortality or the operative and postoperative outcome between both groups. There were, however, difficulties in training an already established consultant in his or her own hospital and these were overcome by certain adjustments to the programme. CONCLUSION Outreach laparoscopic training of colorectal surgeons is a feasible and safe model of training accredited specialists and does not compromise patient care. The challenges encountered can be overcome with optimum training and preparation.
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Affiliation(s)
- M F Hamdan
- Department of General Surgery, Yeovil District Hospital, Yeovil, UK
| | - A Day
- Department of General Surgery, Yeovil District Hospital, Yeovil, UK
| | - J Millar
- Department of General Surgery, Yeovil District Hospital, Yeovil, UK
| | | | - M G Coleman
- Department of General Surgery, Derriford Hospital, Plymouth, UK
| | - N K Francis
- Department of General Surgery, Yeovil District Hospital, Yeovil, UK
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81
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Recent advances in robotic surgery for rectal cancer. Int J Clin Oncol 2015; 20:633-40. [DOI: 10.1007/s10147-015-0854-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/27/2015] [Indexed: 12/24/2022]
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82
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Celentano V, Finch D, Forster L, Robinson JM, Griffith JP. Safety of supervised trainee-performed laparoscopic surgery for inflammatory bowel disease. Int J Colorectal Dis 2015; 30:639-44. [PMID: 25669758 DOI: 10.1007/s00384-015-2147-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE There is a significant risk of surgical resection during the lifetime of an inflammatory bowel disease (IBD) patient: laparoscopic surgery has been increasingly applied to the management of IBD with short and long-term advantages. The aim of this study is to demonstrate that laparoscopic surgery for IBD, performed by a surgical trainee under the supervision of an experienced trainer, is feasible and safe. METHODS All surgical procedures were sub-divided in six critical steps in order to define the procedure as supervised trainee performed (STP) when the trainer was present unscrubbed in the theatre or assisting and trainer performed (TNER) when the trainer performed two or more critical steps of the procedure. Included were all patients undergoing laparoscopic resection for IBD between January 2009 and December 2013. Thirty-day mortality and morbidity were the primary outcomes. Reoperations and rehospitalizations within 30 days of discharge were recorded prospectively and were the secondary outcomes together with conversion rate and length of hospital stay. RESULTS One hundred fifty-one patients were included: 77 (50.99%) STP and 74 (49.01%) TNER. No deaths occurred, and 30-day morbidity was 27.15% with no differences between the groups. Operating time was longer in the STP (166.6 ± 53.31 vs 130.4 ± 49.15). Five patients (2 vs 3) required reoperation (3.31%), while 13 patients (8.6%) required readmission. CONCLUSIONS Laparoscopic surgery for IBD performed by a supervised trainee is safe compared to trainers performed procedures despite a longer operating time. Randomized clinical trials are needed to confirm these preliminary results and to investigate long-term outcomes.
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Park Y, Yong YG, Yun SH, Jung KU, Huh JW, Cho YB, Kim HC, Lee WY, Chun HK. Learning curves for single incision and conventional laparoscopic right hemicolectomy: a multidimensional analysis. Ann Surg Treat Res 2015; 88:269-75. [PMID: 25960990 PMCID: PMC4422880 DOI: 10.4174/astr.2015.88.5.269] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 09/29/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to compare the learning curves and early postoperative outcomes for conventional laparoscopic (CL) and single incision laparoscopic (SIL) right hemicolectomy (RHC). METHODS This retrospective study included the initial 35 cases in each group. Learning curves were evaluated by the moving average of operative time, mean operative time of every five consecutive cases, and cumulative sum (CUSUM) analysis. The learning phase was considered overcome when the moving average of operative times reached a plateau, and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by more than 30 minutes. RESULTS Six patients with missing data in the CL RHC group were excluded from the analyses. According to the mean operative time of every five consecutive cases, learning phase of SIL and CL RHC was completed between 26 and 30 cases, and 16 and 20 cases, respectively. Moving average analysis revealed that approximately 31 (SIL) and 25 (CL) cases were needed to complete the learning phase, respectively. CUSUM analysis demonstrated that 10 (SIL) and two (CL) cases were required to reach a steady state of complication-free performance, respectively. Postoperative complications rate was higher in SIL than in CL group, but the difference was not statistically significant (17.1% vs. 3.4%). CONCLUSION The learning phase of SIL RHC is longer than that of CL RHC. Early oncological outcomes of both techniques were comparable. However, SIL RHC had a statistically insignificant higher complication rate than CL RHC during the learning phase.
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Affiliation(s)
- Yoonah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yuen Geng Yong
- Department of Surgery, Columbia Hospital, Kuala Lumpur, Malaysia, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Zarak A, Castillo A, Kichler K, de la Cruz L, Tamariz L, Kaza S. Robotic versus laparoscopic surgery for colonic disease: a meta-analysis of postoperative variables. Surg Endosc 2015; 29:1341-7. [PMID: 25847139 DOI: 10.1007/s00464-015-4197-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/15/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION An increasing number of studies have been published since the introduction of robotic technology into general surgery. Gastrointestinal surgery is an area of special interest for the robotic surgeon. Colonic surgery can be challenging depending on the disease and the operative approach. We seek to perform a meta-analysis comparing robotic surgery against laparoscopic surgery in this particular field. MATERIALS AND METHODS We performed a systematic search of MEDLINE database from January 2001 to July 2013 supplemented by manual searches of bibliographies of key relevant articles. Randomized controlled trials and cohort studies were selected for review and for collection of postoperative data (length of stay, time to first flatus and complications). RESULTS After careful review, nine studies were considered for analysis. Non-pooled data showed a slight trend toward laparoscopy with increased number of events without statistical significance. Pooled data demonstrated a statistical significance for return to bowel function in the right and mixed robotic colectomy arm (WSMD -0.33, 95 % CI -0.5, -0.1; p < 0.005 and WSMD -0.26, 95 % CI -0.51, 0.0; p = 0.05). Pooled data of length of stay and complications showed no statistical significance between robotic and laparoscopic colonic surgery. DISCUSSION Robotic surgery is a comparable option when dealing with colonic disease, either benign or malignant. No difference in complication rate or length of stay was found when comparing the two. Robotic surgery appears to have an advantage over laparoscopy in regards to return of bowel function when dealing with right colectomies.
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Affiliation(s)
- Alberto Zarak
- Department of Surgery, University of Miami, 5301 S Congress Ave, Atlantis, FL, 33462, USA,
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Cho MS, Kim CW, Baek SJ, Hur H, Min BS, Baik SH, Lee KY, Kim NK. Minimally invasive versus open total mesorectal excision for rectal cancer: Long-term results from a case-matched study of 633 patients. Surgery 2015; 157:1121-9. [PMID: 25737005 DOI: 10.1016/j.surg.2015.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 01/01/2015] [Accepted: 01/20/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND This study compared the long-term oncologic outcomes of patients with rectal cancer who underwent either laparoscopic or robotic total mesorectal excision (TME) via minimally invasive surgery (MIS) to those patient who underwent open TME. METHODS This study was a retrospective, case-control study; patients in the 2 groups were matched according to age, sex, MIS vs open operation, body mass index, tumor location, pathologic TNM stage (ie, tumor-node-metastasis), neoadjuvant treatment, and adjuvant treatment. RESULTS A total of 633 patients (MIS, n = 211; open, n = 422) were assessed. The median follow-up period was 64 (2-124) months. Patient characteristics did not differ between the groups. Overall postoperative complication rates did not differ between the groups (16.0% [MIS]; 17.0% [open]; P = .76). Rates of the involvement of the circumferential resection margin did not differ between the groups (4.0% [MIS]; 5.0% [open]; P = .84). The 5-year overall survival, disease-specific survival, disease-free survival, and local recurrence rates were not different between the MIS and open groups (overall survival = 88.4% vs 85.3%, P = .23; disease-specific survival = 88.8% vs 87.4%, P = .53, disease-free survival = 80.7% vs 78.4%, P = .74; local recurrence = 5.7% vs 5.1%, P = .95). In subgroup analysis, no differences were found in terms of the long-term, oncologic outcomes, oncologic adequacy, and postoperative complications among 3 groups. CONCLUSION We found no differences in the oncologic outcomes between MIS and open surgery, suggesting that MIS for rectal cancer is a safe option for rectal cancer that does not increase the risk of serious complications.
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Affiliation(s)
- Min Soo Cho
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Woo Kim
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Se Jin Baek
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyuk Baik
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Long-term Oncologic Outcomes of Laparoscopic Right Hemicolectomy During the Learning Curve Period. Surg Laparosc Endosc Percutan Tech 2015; 25:52-58. [DOI: 10.1097/sle.0000000000000016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Yeo H, Niland J, Milne D, ter Veer A, Bekaii-Saab T, Farma JM, Lai L, Skibber JM, Small W, Wilkinson N, Schrag D, Weiser MR. Incidence of minimally invasive colorectal cancer surgery at National Comprehensive Cancer Network centers. J Natl Cancer Inst 2014; 107:362. [PMID: 25527640 DOI: 10.1093/jnci/dju362] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Laparoscopic colectomy has been shown to have equivalent oncologic outcomes to open colectomy for the management of colon cancer, but its adoption nationally has been slow. This study investigates the prevalence and factors associated with laparoscopic colorectal resection at National Comprehensive Cancer Network (NCCN) centers. METHODS Data on patients undergoing surgery for colon and rectal cancer at NCCN centers from 2005 to 2010 were obtained from chart review of medical records for the NCCN Outcomes Project and included information on socioeconomic status, insurance coverage, comorbidity, and physician-reported Eastern Cooperative Oncology Group (ECOG) performance status. Associations between receipt of minimally invasive surgery and patient and clinical variables were analyzed with univariate and multivariable logistic regression. All statistical tests were two-sided. RESULTS A total of 4032 patients, diagnosed between September 2005 and December 2010, underwent elective colon or rectal resection for cancer at NCCN centers. Median age of colon cancer patients was 62.6 years, and 49% were men. The percent of colon cancer patients treated with minimally invasive surgery (MIS) increased from 35% in 2006 to 51% in 2010 across all centers but varied statistically significantly between centers. On multivariable analysis, factors associated with minimally invasive surgery for colon cancer patients who had surgery at an NCCN institution were older age (P = .02), male sex (P = .006), fewer comorbidities (P ≤ .001), lower final T-stage (P < .001), median household income greater than or equal to $80000 (P < .001), ECOG performance status = 0 (P = .02), and NCCN institution (P ≤ .001). CONCLUSIONS The use of MIS increased at NCCN centers. However, there was statistically significant variation in adoption of MIS technique among centers.
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Affiliation(s)
- Heather Yeo
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Joyce Niland
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Dana Milne
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Anna ter Veer
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Tanios Bekaii-Saab
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Jeffrey M Farma
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Lily Lai
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - John M Skibber
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - William Small
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Neal Wilkinson
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Martin R Weiser
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW).
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Learning curve for gasless endoscopic thyroidectomy using the trans-axillary approach: CUSUM analysis of a single surgeon's experience. Int J Surg 2014; 12:1273-7. [DOI: 10.1016/j.ijsu.2014.10.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/22/2014] [Accepted: 10/25/2014] [Indexed: 01/30/2023]
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Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers. Surg Endosc 2014; 29:2314-20. [PMID: 25414066 DOI: 10.1007/s00464-014-3950-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 10/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although nowadays considered as feasible and effective surgery in terms of short- and long-term results and oncological radicality, laparoscopic right colectomy is performed by a small number of surgeons, and in the vast majority of cases, this technique was performed with an extracorporeal anastomosis. Current literature failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right colectomy. METHODS A multicenter case-controlled study has been designed, including 286 patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (IA) compared with 226 matched patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (EA). RESULTS There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Surgical post history, tumor localization, and stage of disease according to AJCC/UICC TNM were similar too. Although similar oncologic radicality in term of number of lymph nodes harvested (25.7 ± 10.7 of IA group vs. 24.8 ± 8.7 of EA group; p = 0.3), as well as similar operative time (166 ± 43.7 min. in IA group vs. 157.5 ± 67.2 min in EA group) have been registered, time to flatus was statistically lower after intracorporeal anastomosis (40.8 ± 24.3 h in TLRC group vs. 55.2 ± 19.2 h in LARC group; p < 0.001) Laparoscopic colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 0.65, 95 % CI 0.44, 0.95, p = 0.027). However, when stratifying according to clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 0.63, 95 % CI 0.42, 0.94, p = 0.025), but not for class III, IV, and V complications (OR 1.015, 95 % CI 0.64, 1.6, p = 0.95). CONCLUSION Our results are encouraging to consider the intracorporeally approach the better way to fashion the anastomosis after laparoscopic right colectomy. This study clearly provides the rationale for a randomized clinical trial, which would be useful to give definitive conclusion.
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Park EJ, Kim CW, Cho MS, Kim DW, Min BS, Baik SH, Lee KY, Kim NK. Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer?: a comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries. Medicine (Baltimore) 2014; 93:e109. [PMID: 25437022 PMCID: PMC4616378 DOI: 10.1097/md.0000000000000109] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
As robotic surgery was developed with ergonomic designs, there are expectations that the technical advantages of robotic surgery can shorten the learning curve. However, there is no comparative study, so far, to evaluate the learning curve between robotic and laparoscopic rectal cancer surgeries. Therefore, the aim of this study is to compare the learning curve of robotic low anterior resection (LAR) with laparoscopic LAR for rectal cancer.Patients who underwent robotic or laparoscopic LAR by a single surgeon were compared retrospectively (robot n = 89 vs laparoscopy n = 89). Cumulative sum (CUSUM) was used to evaluate the learning curve. The patients were divided into phase 1 (initial learning curve period) and phase 2 (post-learning curve period). The perioperative clinicopathologic characteristics were compared by phases and surgical procedures.According to CUSUM, the learning curve of robotic LAR was the 44th case and laparoscopic LAR was the 41st case. The learning phases were divided as follows: phase 1 (cases 1-41) versus phase 2 (cases 42-89) in the laparoscopic group, and phase 1 (cases 1-44) versus phase 2 (cases 45-89) in the robotic group. Comparison between phase 1 and phase 2 in each type of surgery showed no significant difference for the perioperative outcomes. Comparison between robotic and laparoscopic surgeries in each phase showed similar perioperative results. Pathologic outcomes were not significantly different in both procedures and phases.The learning curve of robotic LAR for rectal cancer was similar to laparoscopic LAR, and the clinicopathologic outcomes were similar in both the procedures.
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Affiliation(s)
- Eun Jung Park
- Section of Colon and Rectal Surgery (EJP, CWK, MSC, BSM, SHB, KYL, NKK), Department of Surgery; and Biostatistics Collaboration Unit (DWK), Yonsei University College of Medicine, Seoul, Korea
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Chow CFK, Kim SH. Laparoscopic complete mesocolic excision: West meets East. World J Gastroenterol 2014; 20:14301-14307. [PMID: 25339817 PMCID: PMC4202359 DOI: 10.3748/wjg.v20.i39.14301] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 04/07/2014] [Accepted: 06/13/2014] [Indexed: 02/07/2023] Open
Abstract
Complete mesocolic excision is a relatively new concept in western literature. It follows the same concept of total mesorectal excision and units’ routinely performing complete mesocolic excisions have good pathological results as well as good improvements in overall survival, disease free survival and local recurrence. And yet unlike total mesorectal excision, uptake in the West has been relatively slow with many units sceptical of the true benefits gained by taking up a more technically challenging and potentially more morbid procedure when there is a paucity of literature to support these claims. This article reviews complete mesocolic excision for colon cancer, attempting to identify the risks and benefits of the technique and particularly looking at the reasons why its uptake has not been universal. It also discusses the similarities of a complete mesocolic excision to a colon resection with a D3 lymphadenectomy as well as the role of a laparoscopic approach to this technique. Considering a D3 lymphadenectomy has been the standard of care for stage II and III colon cancers in many of our Asian neighbours for over 20 years, combining this data with data on complete mesocolic excision may provide enough evidence to support or refute the need for complete mesocolic excisions. Maybe there might be lessons to be learnt from our colleagues in the east.
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Liang J, Hu Y, Zhao Q, Li Q. Learning curve for endoscope holder in endoscopic thyroidectomy via complete areola approach: a prospective study. Surg Endosc 2014; 29:1920-6. [PMID: 25231555 DOI: 10.1007/s00464-014-3885-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 09/02/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopic thyroidectomy via complete areola approach (ETCAA) is becoming the preferred choice of some patients due to the perfect cosmetic result. Endoscope holder plays an important role in the procedures. Research on the learning curve is helpful in training of endoscope holder and improvement of the whole procedure. METHODS This prospective study investigated 100 consecutive patients who underwent ETCAA performed by a single experienced surgeon and a single inexperienced endoscope holder. Patients were equally divided into ten groups chronologically. One-way analysis of variance, Student-Newman-Keuls test, and Pearson Chi square test were used to analyze statistical significance for clinical data. The correlativity between the operative time and the case number, the endoscope holding score and the case number, the operative time and the interval of neighboring procedures, the endoscope holding score and the interval of neighboring procedures were analyzed with linear regression analysis. RESULTS The mean operative time was 96.30 ± 13.10 min, and the mean endoscope holding score was 74.65 ± 14.08. There were significant differences among the mean operative time (P < 0.0001) and the mean endoscope holding score (P < 0.0001). Multiple comparison revealed that the mean operative time of group 7, 8, 9, 10 were shorter than group 4, 5, 6, meanwhile the mean operative time of group 4, 5, 6 were shorter than group 1, 2, 3. Moreover, the mean endoscope holding score of group 7, 8, 9, 10 were higher than group 4, 5, 6, and the mean endoscope holding score of group 4, 5, 6 were higher than group 1, 2, 3. Linear regression analysis showed negative correlation between the operative time and the case number (r = -0.746, P < 0.0001), positive correlation between the endoscope holding score and the case number (r = 0.765, P < 0.0001), positive correlation between the operative time and the interval of neighboring procedures (r = 0.777, P = 0.008), and negative correlation between the endoscope holding score and the interval of neighboring procedures (r = -0.809, P = 0.005). CONCLUSION A specific learning curve for endoscope holder in ETCAA does exist. The initial 30 cases composed the infancy of the learning curve, and the endoscope holder could expect a learning curve of approximately 60 cases in order to achieve proficiency. Increasing the operating frequency would help shorten the learning curve.
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Affiliation(s)
- Junjie Liang
- Department of Minimally Invasive Surgery, First Affiliated Hospital of Jinan University, NO.613 Huangpu Road, West, Guangzhou, 510630, Guangzhou, China
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Abstract
BACKGROUND Hand-assisted laparoscopic surgery is commonly used in colorectal surgery and provides benefit in complex cases. OBJECTIVE This study examined the minimally invasive surgical trends, patient characteristics, and operative variables unique to patients undergoing hand-assisted laparoscopic surgery. DESIGN This was a retrospective medical chart review. SETTINGS The study was conducted in a tertiary care medical center. PATIENTS Patients included in the study were those who underwent pure laparoscopic colectomies, hand-assisted laparoscopic colectomies, and traditional open surgery for elective treatment of diverticular disease, colorectal cancer, IBD, and benign polyp disease. MAIN OUTCOME MEASURES Primary outcomes included patient characteristics and operative variables unique to patients undergoing hand-assisted laparoscopic surgery and documentation of operative technique trends within an experienced colorectal group. RESULTS Diverticular disease characteristics specific to hand-assisted laparoscopic surgery included the presence of dense inflammatory adhesions (p < 0.0001), diverticular fistulas (p < 0.0001), and unresolved phlegmon (p = 0.0003). Characteristics specific for colorectal cancer included intraoperative tumor bulk (p < 0.0001) and the inability to achieve appropriate surgical resection margins (p < 0.001). Similarly, variables identified for benign polyp disease included adhesions (p < 0.0001) and the ability to gain adequate exposure (p < 0.0001). Limited use of hand-assisted laparoscopic surgery was observed in patients with IBD. LIMITATIONS This was a retrospective, observational study from a single center. CONCLUSIONS Conversion to hand-assisted laparoscopic surgery provides benefit in surgical scenarios where dense inflammatory adhesions, diverticular fistulas, and intra-abdominal postdiverticulitis phlegmon are present. In addition, benefit is observed in patients with colorectal cancer where laparoscopic dissection of bulky tumor proves to be difficult and where the technical ability to obtain margins using pure laparoscopy is compromised. Although our practice has changed to favor pure laparoscopy, hand-assisted laparoscopic surgery continues to play an important role in complex colorectal cases that otherwise would require open surgery (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A146).
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95
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Vera AM, Russo M, Mohsin A, Tsuda S. Augmented reality telementoring (ART) platform: a randomized controlled trial to assess the efficacy of a new surgical education technology. Surg Endosc 2014; 28:3467-72. [PMID: 24962856 DOI: 10.1007/s00464-014-3625-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 05/16/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Laparoscopic skills training has evolved over recent years. However, conveying a mentor's directions using conventional methods, without realistic on-screen visual cues, can be difficult and confusing. To facilitate laparoscopic skill transference, an augmented reality telementoring (ART) platform was designed to overlay the instruments of a mentor onto the trainee's laparoscopic monitor. The aim of this study was to compare the effectiveness of this new teaching modality to traditional methods in novices performing an intracorporeal suturing task. METHODS Nineteen pre-medical and medical students were randomized into traditional mentoring (n = 9) and ART (n = 10) groups for a laparoscopic suturing and knot-tying task. Subjects received either traditional mentoring or ART for 1 h on the validated fundamentals of laparoscopic surgery intracorporeal suturing task. Tasks for suturing were recorded and scored for time and errors. Results were analyzed using means, standard deviation, power regression analysis, correlation coefficient, analysis of variance, and student's t test. RESULTS Using Wright's cumulative average model (Y = aX (b)) the learning curve slope was significantly steeper, demonstrating faster skill acquisition, for the ART group (b = -0.567, r (2) = 0.92) than the control group (b = -0.453, r (2) = 0.74). At the end of 10 repetitions or 1 h of practice, the ART group was faster versus traditional (mean 167.4 vs. 242.4 s, p = 0.014). The ART group also had fewer fails (8) than the traditional group (13). CONCLUSION The ART Platform may be a more effective training technique in teaching laparoscopic skills to novices compared to traditional methods. ART conferred a shorter learning curve, which was more pronounced in the first 4 trials. ART reduced the number of failed attempts and resulted in faster suture times by the end of the training session. ART may be a more effective training tool in laparoscopic surgical training for complex tasks than traditional methods.
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Affiliation(s)
- Angelina M Vera
- University of Nevada School of Medicine, Las Vegas, NV, USA,
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Abstract
Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.
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Affiliation(s)
- Hoda Samia
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sadaf Khan
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Justin Lawrence
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Conor P Delaney
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
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Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3-phase learning process comparison. Surg Endosc 2014; 28:2821-31. [DOI: 10.1007/s00464-014-3569-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/21/2014] [Indexed: 01/27/2023]
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98
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The Impact of a Pelvic Pillow on Learning How to Perform Laparoscopic Low Anterior Resection for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2014; 24:259-63. [DOI: 10.1097/sle.0b013e31828fa659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bogen EM, Augestad KM, Patel HRH, Lindsetmo RO. Telementoring in education of laparoscopic surgeons: An emerging technology. World J Gastrointest Endosc 2014; 6:148-55. [PMID: 24944728 PMCID: PMC4024487 DOI: 10.4253/wjge.v6.i5.148] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 03/31/2014] [Accepted: 04/17/2014] [Indexed: 02/05/2023] Open
Abstract
Laparoscopy, minimally invasive and minimal access surgery with more surgeons performing these advanced procedures. We highlight in the review several key emerging technologies such as the telementoring and virtual reality simulators, that provide a solid ground for delivering surgical education to rural area and allow young surgeons a safety net and confidence while operating on a newly learned technique.
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Safety of laparoscopic colorectal surgery in a low-volume setting: review of early and late outcome. Gastroenterol Res Pract 2014; 2014:581523. [PMID: 24799890 PMCID: PMC3996862 DOI: 10.1155/2014/581523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 02/08/2023] Open
Abstract
Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases.
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