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Wang Y, Wen D, Zhang C, Wang Z, Zhang J. A novel training program: laparoscopic versus robotic-assisted low anterior resection for rectal cancer can be trained simultaneously. Front Oncol 2023; 13:1169932. [PMID: 37441427 PMCID: PMC10334189 DOI: 10.3389/fonc.2023.1169932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
Background Current expectations are that surgeons should be technically proficient in minimally invasive low anterior resection (LAR)-both laparoscopic and robotic-assisted surgery. However, methods to effectively train surgeons for both approaches are under-explored. We aimed to compare two different training programs for minimally invasive LAR, focusing on the learning curve and perioperative outcomes of two trainee surgeons. Methods We reviewed 272 consecutive patients undergoing laparoscopic or robotic LAR by surgeons A and B, who were novices in conducting minimally invasive colorectal surgery. Surgeon A was trained by first operating on 80 cases by laparoscopy and then 56 cases by robotic-assisted surgery. Surgeon B was trained by simultaneously performing 80 cases by laparoscopy and 56 by robotic-assisted surgery. The cumulative sum (CUSUM) method was used to evaluate the learning curves of operative time and surgical failure. Results For laparoscopic surgery, the CUSUM plots showed a longer learning process for surgeon A than surgeon B (47 vs. 32 cases) for operative time, but a similar trend in surgical failure (23 vs. 19 cases). For robotic surgery, the plots of the two surgeons showed similar trends for both operative times (23 vs. 25 cases) and surgical failure (17 vs. 19 cases). Therefore, the learning curves of surgeons A and B were respectively divided into two phases at the 47th and 32nd cases for laparoscopic surgery and at the 23rd and 25th cases for robotic surgery. The clinicopathological outcomes of the two surgeons were similar in each phase of the learning curve for each surgery. Conclusions For surgeons with rich experience in open colorectal resections, simultaneous training for laparoscopic and robotic-assisted LAR of rectal cancer is safe, effective, and associated with accelerated learning curves.
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Affiliation(s)
| | | | | | - Zhikai Wang
- *Correspondence: Jiancheng Zhang, ; Zhikai Wang,
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Burghgraef TA, Sikkenk DJ, Crolla RMPH, Fahim M, Melenhorst J, Moumni ME, Schelling GVD, Smits AB, Stassen LPS, Verheijen PM, Consten ECJ. Assessing the learning curve of robot-assisted total mesorectal excision: a multicenter study considering procedural safety, pathological safety, and efficiency. Int J Colorectal Dis 2023; 38:9. [PMID: 36630001 PMCID: PMC9834356 DOI: 10.1007/s00384-022-04303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Evidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore, this study aims to assess the learning curve of robot-assisted total mesorectal excision. METHODS A retrospective study was performed in four Dutch centers. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications, and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared. RESULTS In this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12 to 35 cases. Intraoperative, postoperative, and pathological outcomes did not differ between patients operated during and after the learning curve. CONCLUSION The learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined limits and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
| | - D J Sikkenk
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M Fahim
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M El Moumni
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - A B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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Harji D, Aldajani N, Cauvin T, Chauvet A, Denost Q. Parallel, component training in robotic total mesorectal excision. J Robot Surg 2022; 17:1049-1055. [PMID: 36515819 DOI: 10.1007/s11701-022-01496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
There has been widespread adoption of robotic total mesorectal excision (TME) for rectal cancer in recent years. There is now increasing interest in training robotic novice surgeons in robotic TME surgery using the principles of component-based learning. The aims of our study were to assess the feasibility of delivering a structured, parallel, component-based, training curriculum to surgical trainees and fellows. A prospective pilot study was undertaken between January 2021 and May 2021. A dedicated robotic training pathway was designed with two trainees trained in parallel per each robotic case based on prior experience, training grade and skill set. Component parts of each operation were allocated by the robotic trainer prior to the start of each case. Robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and the EARCS Global Assessment Score (GAS). Three trainees participated in this pilot study, performing a combined number of 52 TME resections. Key components of all 52 TME operations were performed by the trainees. GEARS scores improved throughout the study, with a mean overall baseline score of 17.3 (95% CI 15.1-1.4) compared to an overall final assessment mean score of 23.8 (95% CI 21.6-25.9), p = 0.003. The GAS component improved incrementally for all trainees at each candidate assessment (p < 0.001). Employing a parallel, component-based approach to training in robotic TME surgery is safe and feasible and can be used to train multiple trainees of differing grades simultaneously, whilst maintaining high-quality clinical outcomes.
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Affiliation(s)
- Deena Harji
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Nour Aldajani
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Thomas Cauvin
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Alexander Chauvet
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Quentin Denost
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
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Burghgraef TA, Sikkenk DJ, Verheijen PM, Moumni ME, Hompes R, Consten ECJ. The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review. Surg Endosc 2022; 36:6337-6360. [PMID: 35697853 PMCID: PMC9402498 DOI: 10.1007/s00464-022-09087-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME. METHODS A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias. RESULTS 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods. CONCLUSION Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
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Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Daan J Sikkenk
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Mostafa El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, University Medical Center Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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Ding HB, Wang LH, Sun G, Yu GY, Gao XH, Zheng K, Gong HF, Sui JK, Zhu XM, Zhang W. Evaluation of the learning curve for conformal sphincter preservation operation in the treatment of ultralow rectal cancer. World J Surg Oncol 2022; 20:102. [PMID: 35354489 PMCID: PMC8966240 DOI: 10.1186/s12957-022-02541-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/27/2022] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultralow rectal cancer and to further explore the influencing factors of operation time. Methods From August 2011 to April 2020, 108 consecutive patients with ultralow rectal cancer underwent CSPO by the same surgeon in the Department of Colorectal Surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis. Results According to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1–45 cases) and learning completion period (46–108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05), and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. < 4cm, P = 0.039) and T stage (T3 vs. T1-2, P = 0.022) was independent risk factors for prolonging the operation time of CSPO. Conclusions For surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultralow rectal cancer whose distance of tumor from anal verge is less than 4 cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence, and shorten the learning curve on the premise of safety.
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Garcia LE, Taylor J, Atallah C. Update on Minimally Invasive Surgical Approaches for Rectal Cancer. Curr Oncol Rep 2021; 23:117. [PMID: 34342706 DOI: 10.1007/s11912-021-01110-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This review aims to clarify the current role of minimally invasive surgery in the treatment of rectal cancer, highlighting short- and long-term outcomes from the latest trials and studies. RECENT FINDINGS Data from previous trials has been conflicting, with some failing to demonstrate non-inferiority of laparoscopic surgical resection of rectal cancer compared to an open approach and others demonstrating similar clinical outcomes. Robot-assisted surgery was thought to be a promising solution to the challenges faced by laparoscopic surgery, and even though the only randomized controlled trial to date comparing these two techniques did not show superiority of robot-assisted surgery over laparoscopy, more recent retrospective data suggests a statistically significant higher negative circumferential resection margin rate, decreased frequency of conversion to open, and less sexual and urinary complications. Minimally invasive surgery techniques for resection of rectal cancer, particularly robot-assisted, offer clear short-term peri-operative benefits over an open approach; however, current data has yet to display non-inferiority in terms of oncological outcomes.
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Affiliation(s)
- Leonardo E Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA
| | - James Taylor
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA
| | - Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA.
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Wang Y, Wang G, Li Z, Ling H, Yi B, Zhu S. Comparison of the operative outcomes and learning curves between laparoscopic and "Micro Hand S" robot-assisted total mesorectal excision for rectal cancer: a retrospective study. BMC Gastroenterol 2021; 21:251. [PMID: 34098897 PMCID: PMC8186043 DOI: 10.1186/s12876-021-01834-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The Micro Hand S robot is a new surgical tool that has been applied to total mesorectal excision (TME) surgery for rectal cancer in our center. In this study, we compared the operative outcomes, functional outcomes and learning curves of the Micro Hand S robot-assisted TME (RTME) with laparoscopic TME (LTME). METHODS A total of 40 patients who underwent RTME and 65 who underwent LTME performed by a single surgeon between July 2015 and November 2018 were included in this retrospective study. Clinicopathologic characteristics, operative and functional outcomes, and learning curves were compared between the two groups. The learning curve was analyzed using the cumulative sum method and two stages (Phase 1, Phase 2) were identified and analyzed. All patients were followed up for at least 12 months. RESULTS The clinicopathologic characteristics of the two groups were similar. The learning curve was 17 cases for RTME and 34 cases for LTME. Compared with LTME, RTME was associated with less blood loss (148.2 vs. 195.0 ml, p = 0.022), and shorter length of hospital stay (9.5 vs. 12.2 days, p = 0.017), even during the learning period. With the accumulation of experience, the operative time decreased significantly from Phase 1 to Phase 2 (RTME, 360.6 vs. 323.5 min, p = 0.009; LTME, 338.1 vs. 301.9 min, p = 0.005), whereas other outcomes did not differ significantly. CONCLUSIONS Micro Hand S robot-assisted TME is safe and feasible even during the learning period, with outcomes comparable to laparoscopic surgery but superior in terms of blood loss, length of hospital stay, and learning curve. Trial registration Clinicaltrial.gov, NCT04836741, retrospectively registered on 5 April 2021.
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Affiliation(s)
- Yanlei Wang
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China
| | - Guohui Wang
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China
| | - Zheng Li
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China
| | - Hao Ling
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China
| | - Bo Yi
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China.
| | - Shaihong Zhu
- Department of General Surgery, Third Xiangya Hospital, Central South University, 138 Tongzipo Street, Changsha, 410013, Hunan, China.
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Antoun A, Chau J, Alsharqawi N, Kaneva P, Feldman LS, Mueller CL, Lee L. P338: summarizing measures of proficiency in transanal total mesorectal excision—a systematic review. Surg Endosc 2020; 35:4817-4824. [DOI: 10.1007/s00464-020-07935-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 01/01/2023]
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