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Verhoeff K, Glinka J, Quan D, Skaro A, Tang ES. Laparoscopic versus open hepatic resection in patients ≥75 years old: A NSQIP analysis evaluating 2674 patients. J Surg Oncol 2024. [PMID: 39155695 DOI: 10.1002/jso.27820] [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: 07/27/2024] [Accepted: 08/04/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Previous studies report promising outcomes with minimally invasive (MIS) hepatectomy in elderly patients but remain limited by small size. This study aims to comparatively evaluate the demographics and outcomes of geriatric patients undergoing MIS and open hepatectomy. METHOD The 2016-2021 NSQIP database was evaluated comparing patients ≥75 undergoing MIS versus open hepatectomy. Patient selection and outcomes were compared using bivariate analysis with multivariable modeling (MVR) evaluating factors associated with serious complications and mortality. Propensity score matched (PSM) analysis further evaluated serious complications, mortality, length of stay (LOS), Clavien Dindo Classification (CDC), and Comprehensive Complication Index (CCI) for cohorts. RESULTS We evaluated 2674 patients with 681 (25.5%) receiving MIS hepatectomy. MIS approaches were used more for partial lobectomy (85.9% vs. 61.7%; p < 0.001), and required fewer biliary reconstructions (1.6% vs. 10.6%; p < 0.001). Patients were similar with regards to sex, body mass index, and other comorbidities. Unadjusted analysis demonstrated that MIS approaches had fewer serious complications (8.8% vs. 18.7%; p < 0.001). However, after controlling for cohort differences the MIS approach was not associated with reduced likelihood of serious complications (odds ratio [OR]: 0.77; p = 0.219) or mortality (OR: 1.19; p = 0.623). PSM analysis further supported no difference in serious complications (p = 0.403) or mortality (p = 0.446). However, following PSM a significant reduction in LOS (-1.99 days; p < 0.001), CDC (-0.26 points; p = 0.016) and CCI (-2.79 points; p = 0.022) was demonstrated with MIS approaches. CONCLUSIONS This is the largest study comparing MIS and open hepatectomy in elderly patients. Results temper previously reported outcomes but support reduced LOS and complications with MIS approaches.
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Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Juan Glinka
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Douglas Quan
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Anton Skaro
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Ephraim S Tang
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
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Cawich SO, Shukla PJ, Shrikhande SV, Dixon E, Pearce NW, Deshpande R, Francis W. Time to retire the term "high volume" and replace with "high quality" for HPB centers: A position statement from Caribbean chapter of AHPBA. Surgeon 2024; 22:e117-e119. [PMID: 38135631 DOI: 10.1016/j.surge.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Shamir O Cawich
- University of the West Indies, St Augustine, Trinidad & Tobago, West Indies.
| | - Parul J Shukla
- Northwell Health, Professor of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | | | | | - Neil W Pearce
- Southampton University Hospital NHS Trust, Southampton, United Kingdom
| | - Rahul Deshpande
- Manchester Royal Infirmary and Christie Hospital, Manchester, UK
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Champavier PG, Beyer-Berjot L, Arnoux PJ, Py M, Casanova R, Berdah S, Birnbaum DJ, Guilbaud T. An Ex Situ Cadaver Liver Training Model Continuously Pressurized to Simulate Specific Skills Involved in Laparoscopic Liver Resection: the Lap-Liver Trainer. J Gastrointest Surg 2023; 27:521-533. [PMID: 36624325 DOI: 10.1007/s11605-022-05566-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) requires delicate skills. The aim of the study was to develop a training model mimicking as much as possible intraoperative bleeding and bile leakage during LLR. We also assessed the educational value of the training model. METHODS The Lap-liver trainer (LLT) combined a continuously pressurized ex situ cadaver liver and a customized mannequin. The customized mannequin was designed by computer-aided design and manufactured by 3D printing. The left lateral sectionectomy (LLS) was chosen to assess the feasibility of a LLR with the LLT. Eighteen volunteers were recruited to perform LLS and to assess the educational value of the LLT using a Likert scale. RESULTS The customized mannequin consisted of a close laparoscopic training device based on a simplified reconstruction of the abdominal cavity in laparoscopic conditions. Ex situ cadaver livers were pressurized to simulate blood and bile supplies. Each expert surgeon (n = 3) performed two LLS. They were highly satisfied of simulation conditions (4.80 ± 0.45) and strongly recommended that the LLT should be incorporated into a teaching program (5.00 ± 0.0). Eight novice and 4 intermediate surgeons completed a teaching program and performed a LLS. Overall, the level of satisfaction was high (4.92 ± 0.29), and performing such a procedure under simulation conditions benefited their learning and clinical practice (4.92 ± 0.29). CONCLUSIONS The LLT could provide better opportunities for trainees to acquire and practice LLR skills in a more realistic environment and to improve their ability to deal with specific events related to LLR.
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Affiliation(s)
| | - Laura Beyer-Berjot
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | | | - Max Py
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | | | - Stéphane Berdah
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | - David Jérémie Birnbaum
- Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | - Théophile Guilbaud
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
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Shi H, Lu P, Yu D, Wang J, Wang Z, Zhuang B, Shao C, Liu C, Liu B. The training of wrist arthroscopy. Front Med (Lausanne) 2022; 9:947459. [PMID: 36590938 PMCID: PMC9800421 DOI: 10.3389/fmed.2022.947459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
The wrist is a complex joint that bridges the hand to the forearm. Patients with wrist disorders increasingly prefer minimally invasive procedures for wrist joint diagnosis and treatment. Wrist arthroscopy offers direct visualization of the structures of the joint anatomy and existing disease processes while causing minimal damage to surrounding soft tissue. However, it requires a high level of technical ability for wrist arthroscopy practitioners. Therefore, an improved focus on wrist arthroscopy training combining new educational media and traditional practice should aid in the development of novel wrist arthroscopy training mode. This article aims to describe the status of wrist training and evaluation systems and introduce a new progressive wrist training system.
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Affiliation(s)
- Haifei Shi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Pan Lu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China,Pan Lu
| | - Dongdong Yu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiwen Wang
- China Academy of Space Technology, Beijing Institute of Control Engineering, Beijing, China
| | - Zhenhua Wang
- China Academy of Space Technology, Beijing Institute of Control Engineering, Beijing, China
| | - Baotang Zhuang
- China Academy of Space Technology, Beijing Institute of Control Engineering, Beijing, China
| | - Chao Shao
- China Academy of Space Technology, Beijing Institute of Control Engineering, Beijing, China
| | - Chang Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Xicheng District, Beijing, China
| | - Bo Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Xicheng District, Beijing, China,*Correspondence: Bo Liu
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Sivakumar J, Chen Q, Hii MW, Cullinan M, Choi J, Steven M, Crosthwaite G. Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression. Surg Endosc 2022; 37:2453-2475. [PMID: 36416945 DOI: 10.1007/s00464-022-09760-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained. METHODS A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase of the curve. RESULTS Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30). CONCLUSION Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.
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Affiliation(s)
- Jonathan Sivakumar
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia.
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia.
- Department of Surgery, The University of Melbourne, Melbourne, Australia.
| | - Qianyu Chen
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Michael W Hii
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Mark Cullinan
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, Monash University, Clayton, VIC, Australia
| | - Julian Choi
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Upper Gastrointestinal and Hepatobiliary Surgery, Western Health, Melbourne, Australia
| | - Mark Steven
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
| | - Gary Crosthwaite
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
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Crema E, Melani AGF, Romagnolo LGC, Marescaux J. Ten years of IRCAD, Barretos, SP, Brazil. Acta Cir Bras 2022; 37:e370608. [PMID: 36134854 PMCID: PMC9488511 DOI: 10.1590/acb370608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/20/2022] [Indexed: 11/22/2022] Open
Abstract
Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.
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Affiliation(s)
- Eduardo Crema
- PhD, full professor. Universidade Federal do Triângulo Mineiro - Division of Digestive Tract Surgery - Uberaba (MG), Brazil
| | - Armando Geraldo Franchini Melani
- MSc, technical and scientific director. IRCAD Latin America, and physician at Americas Integrated Oncology Center - Rio de Janeiro (RJ), Brazil
| | - Luís Gustavo Capochin Romagnolo
- MD. Hospital de Câncer de Barretos - Pio XII Foundation, and scientific coordinator, IRCAD Latin America - Barretos (SP), Brazil
| | - Jacques Marescaux
- MD, founder and scientific coordinator. IRCAD Latin America - Barretos (SP), Brazil
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Lopez-Lopez V, López-Conesa A, Brusadin R, Perez-Flores D, Navarro-Barrios Á, Gomez-Valles P, Cayuela V, Robles-Campos R. Pure laparoscopic vs. hand-assisted liver surgery for segments 7 and 8: propensity score matching analysis. Surg Endosc 2022; 36:4470-4478. [PMID: 34697682 DOI: 10.1007/s00464-021-08800-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Laparoscopic liver resection of tumors located in segments 7 and 8 are considered a complex resection. The aim of this study was to compare the intraoperative and early postoperative outcomes of patients operated by pure laparoscopic (PLS) vs hand-assisted laparoscopic surgery (HALS). METHODS From January 2003 to January 2021, we included patients with minimally invasive surgery for lesions located in segments 7 and 8. To overcome selection bias, we performed 1:1 propensity score matching (PSM) between HALS and PLS cohorts, including 30 patients in each of the groups. Of the 60 patients who underwent PSM, we compared the first 30 patients with the following 30 patients. RESULTS A total of 79 LLRs were performed, 46 by HALS and 33 by PLS. After PSM, in the PLS cohort, cirrhosis was more frequent (33.3% vs. 13.3%, p = 0.02). The surgical time, blood loss, Pringle maneuver, clamping time, and morbidity were similar between both groups, but with a lower hospital stay in the PLS group (3 days vs. 4 days, p < 0.01). In the first 30 patients who underwent LLR, the use of PLS was lower than the use of HALS, increasing due to the learning curve (16.7% in the first period vs. 83.3% in the second period; p < 0.01). The hospital stay was lower in the second period due to the more frequent use of PLS (3 vs. 4 days, p < 0.01). CONCLUSION PLS presents similar intraoperative and early postoperative results with lower hospital stay for lesions located in segments 7 and 8 compared to HALS. In centers with experience in LLRs, PLS could be performed safely in these segments.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Asunción López-Conesa
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | | | - Álvaro Navarro-Barrios
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Paula Gomez-Valles
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Valentín Cayuela
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain.
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Ackermann J, Pahls J, Baumann J, Spüntrup C, Holthaus B, Noé G, Anapolski M, Meinhold-Heerlein I, Laganà AS, Peters G, Pape J, Willer D, Westermann AM, Günther V, Maass N, Mettler L, Alkatout I. The pelvitrainer for training in laparoscopic surgery – A prospective, multicenter, interdisciplinary study: Experimental research. Int J Surg 2022; 101:106604. [DOI: 10.1016/j.ijsu.2022.106604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022]
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Banas B, Kolodziejczyk P, Czerw A, Banas T, Kotwas A, Richter P. A Retrospective, Single-Centre Study on the Learning Curve for Liver Tumor Open Resection in Patients with Hepatocellular Cancers and Intrahepatic Cholagangiocarcinomas. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4872. [PMID: 35457739 PMCID: PMC9031011 DOI: 10.3390/ijerph19084872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Liver resections have become the first-line treatment for primary malignant tumors and, therefore, are considered a core aspect of surgical training. This study aims to evaluate the learning curve for the safety of open hemihepatectomy procedures for patients suffering from hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC). METHODS This single tertiary center retrospective analysis includes 81 consecutive cases of right or left hemihepatectmy. A cumulative sum (CUSUM) control chart was used to investigate the learning curve. RESULTS The CUSUM curve for operative time and blood loss level peaked at the 29th and 30th case, respectively. The CUSUM curve for minor adverse effects (mAEs) and severe adverse effects (sAEs) showed a downward slope after the 27th and 36th procedures; the curve, however, remained within the acceptable range throughout the entire study. CONCLUSION When performing open hemihepatectomies in patients with HCC and ICC, the stabilization of the operative time and intraoperative blood loss level are gained earlier than sAEs risk reduction.
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Affiliation(s)
- Bartlomiej Banas
- First Department of Surgery, Jagiellonian University Medical College, 30-688 Krakow, Poland; (P.K.); (P.R.)
| | - Piotr Kolodziejczyk
- First Department of Surgery, Jagiellonian University Medical College, 30-688 Krakow, Poland; (P.K.); (P.R.)
| | - Aleksandra Czerw
- Department of Health Economics and Medical Law, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Department of Economic and System Analyses, National Institute of Public Health NIH—National Research Institute, 00-791 Warsaw, Poland
| | - Tomasz Banas
- Department of Gynaecology and Oncology, Jagiellonian University Medical College, 31-501 Krakow, Poland;
- Department of Radiotherapy, Oncology Centre, Maria Sklodowska-Curie Institute, 30-688 Krakow, Poland
| | - Artur Kotwas
- Sub-Department of Social Medicine and Public Health, Department of Social Medicine, Pomeranian Medical University, 71-210 Szczecin, Poland;
| | - Piotr Richter
- First Department of Surgery, Jagiellonian University Medical College, 30-688 Krakow, Poland; (P.K.); (P.R.)
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Herrera-Aliaga E, Estrada LD. Trends and Innovations of Simulation for Twenty First Century Medical Education. Front Public Health 2022; 10:619769. [PMID: 35309206 PMCID: PMC8929194 DOI: 10.3389/fpubh.2022.619769] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
In the last two decades there has been an enormous growth in the use of clinical simulation. This teaching-learning methodology is currently the main tool used in the training of healthcare professionals. Clinical simulation is in tune with new paradigms in education and is consistent with educational theories that support the use of experiential learning. It promotes the development of psychomotor skills and strengthens executive functions. This pedagogical approach can be applied in many healthcare topics and is particularly relevant in the context of restricted access to clinical settings. This is particularly relevant considering the current crisis caused by the COVID-19 pandemic, or when trying to reduce the frequency of accidents attributed to errors in clinical practice. This mini-review provides an overview of the current literature on healthcare simulation methods, as well as prospects for education and public health benefits. A literature search was conducted in order to find the most current trends and state of the art in medical education simulation. Presently, there are many areas of application for this methodology and new areas are constantly being explored. It is concluded that medical education simulation has a solid theoretical basis and wide application in the training of health professionals at present. In addition, it is consolidated as an unavoidable methodology both in undergraduate curricula and in continuing medical education. A promising scenario for medical education simulation is envisaged in the future, hand in hand with the development of technological advances.
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Affiliation(s)
| | - Lisbell D. Estrada
- Faculty of Health Sciences, Universidad Bernardo O'Higgins, Santiago, Chile
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11
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Sena G, Picciariello A, Marino F, Goglia M, Rocca A, Meniconi RL, Gallo G. One-Stage Total Laparoscopic Treatment for Colorectal Cancer With Synchronous Metastasis. Is It Safe and Feasible? Front Surg 2021; 8:752135. [PMID: 34869559 PMCID: PMC8637405 DOI: 10.3389/fsurg.2021.752135] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/18/2021] [Indexed: 12/28/2022] Open
Abstract
Liver is the main target organ for colorectal cancer (CRC) metastases. It is estimated that ~25% of CRC patients have synchronous metastases at diagnosis, and about 60% of CRC patients will develop metastases during the follow up. Although several teams have performed simultaneous laparoscopic resections (SLR) of liver and colorectal lesions, the feasibility and safety of this approach is still widely debated and few studies on this topic are present in the literature. The purpose of this literature review is to understand the state of the art of SLR and to clarify the potential benefits and limitations of this approach. Several studies have shown that SLR can be performed safely and with short-term outcomes similarly to the separated procedures. Simultaneous laparoscopic colorectal and hepatic resections combine the advantages of one stage surgery with those of laparoscopic surgery. Several reports compared the short-term outcomes of one stage laparoscopic resection with open resections and showed a similar or inferior amount of blood loss, a similar or lower complication rate, and a significant reduction of hospital stay for laparoscopic surgery respect to open surgery but much longer operating times for the laparoscopic technique. Few retrospective studies compared long term outcomes of laparoscopic one stage surgery with the outcomes of open one stage surgery and did not identify any differences about disease free survival and the overall survival. In conclusion, hepatic and colorectal SLR are a safe and effective approach characterized by less intraoperative blood loss, faster recovery of intestinal function, and shorter length of postoperative hospital stay. Moreover, laparoscopic approach is associated to lower rates of surgical complications without significant differences in the long-term outcomes compared to the open surgery.
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Affiliation(s)
- Giuseppe Sena
- Department of Vascular Surgery, "Pugliese-Ciaccio" Hospital, Catanzaro, Italy
| | | | - Fabio Marino
- Unit of Surgery, National Institute of Gastroenterology "Saverio de Bellis," Research Hospital, Castellana Grotte, Italy
| | - Marta Goglia
- Department of General Surgery, "La Sapienza" University of Rome-Sant'Andrea University Hospital, Rome, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| | - Roberto L Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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12
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Katagiri H, Nitta H, Takahara T, Hasegawa Y, Kanno S, Umemura A, Takeda D, Makabe K, Kikuchi K, Kimura T, Yanari S, Sasaki A. Standardized single-incision plus one-port laparoscopic left lateral sectionectomy: a safe alternative to the conventional procedure. Langenbecks Arch Surg 2021; 407:1277-1284. [PMID: 34866161 PMCID: PMC9151572 DOI: 10.1007/s00423-021-02340-4] [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] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 09/22/2021] [Indexed: 01/22/2023]
Abstract
Purpose Laparoscopic left lateral sectionectomy (LLLS) is a feasible and safe procedure with a relatively smooth learning curve. However, single-incision LLLS requires extensive surgical experience and advanced techniques. The aim of this study is to report the standardized single-incision plus one-port LLLS (reduced port LLLS, RPLLLS) technique and evaluate its safety, feasibility, and effectiveness for junior surgeons. Methods Between January 2008 and November 2020, the clinical records of 49 patients who underwent LLLS, divided into the conventional LLLS (n = 37) and the RPLLLS group (n = 12), were retrospectively reviewed. The patient characteristics, pathologic results, and operative outcomes were evaluated. Results A history of previous abdominal surgery in the RPLLLS group was significantly high (56.8% vs. 91.7%, p = 0.552). Notably, junior surgeons performed 62.2% of the conventional LLLSs and 58.4% of the standardized RPLLLSs. There were no significant differences between the two groups in terms of median operative time (121.0 vs. 113.5, p = 0.387), median blood loss (13.0 vs. 8.5, p = 0.518), median length of hospital stays (7.0 vs. 7.0, p = 0.408), and morbidity rate (2.7% vs. 0%, p = 0.565), respectively. Conclusion This standardized RPLLLS is a feasible and safe alternative to conventional LLLS and may become the ideal training procedure for both junior surgeons and surgeons aiming to learn more complex procedures.
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Affiliation(s)
- Hirokatsu Katagiri
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan.
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Takeshi Takahara
- Department of Surgery, Fujita-Gakuen Health University School of Medicine, Aichi, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Syoji Kanno
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Akira Umemura
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Daiki Takeda
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Kenji Makabe
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Koji Kikuchi
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Taku Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Shingo Yanari
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3609, Japan
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13
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Ivanecz A, Plahuta I, Mencinger M, Perus I, Magdalenic T, Turk S, Potrc S. The learning curve of laparoscopic liver resection utilising a difficulty score. Radiol Oncol 2021; 56:111-118. [PMID: 34492748 PMCID: PMC8884855 DOI: 10.2478/raon-2021-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/16/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND This study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon. PATIENTS AND METHODS A retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Halls difficulty score (HDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between HDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve. RESULTS The obtained learning curve has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved. CONCLUSIONS This learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).
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Affiliation(s)
- Arpad Ivanecz
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Irena Plahuta
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Matej Mencinger
- Faculty of Civil Engineering, Transportation Engineering and Architecture, University of Maribor, Maribor, Slovenia
- Centre of Applied Mathematics and Theoretical Physics, University of Maribor, Maribor, Slovenia
- Institute of Mathematics, Physics and Mechanics, Ljubljana, Slovenia
| | - Iztok Perus
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Natural Science and Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Tomislav Magdalenic
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Spela Turk
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Stojan Potrc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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14
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Tsekouras K, Spartalis E, Mamakos N, Tsourouflis G, Nikiteas NI, Dimitroulis D. The Use of Robotics in Surgery of Benign Liver Diseases: A Systematic Review. Surg Innov 2021; 29:258-268. [PMID: 34275339 DOI: 10.1177/15533506211031414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Surgical treatment of benign liver diseases (BLD) remains a field of conflict, due to increased risk and high complication rate. However, the introduction of minimally invasive surgery has led to increased number of patients with BLD being treated surgically, with similar outcomes and fewer complications. Current data support the application of laparoscopic surgery (LS) and robotic surgery (RS) in surgical treatment of liver malignancies, but there are insufficient data concerning the application of robotic surgery in BLD. In the present systematic review, we aimed to evaluate the application of RS in BLD surgery. METHODS After a thorough search of Medline, Scopus, and Cochrane Library, 12 studies were considered eligible with a total number of 115 patients with BLD. DISCUSSION In brief, RS appears to be a safe and feasible option for BLD surgery. When compared to open surgery, RS is associated with lower blood loss, shorter length of stay, and fewer complication rate. Regarding LS, the peri- and postoperative outcomes were similar, but RS can overcome the technical limitations of LS. However, the cost of RS remains a major drawback in its widespread application. CONCLUSIONS Considering our findings, RS can be a safe and feasible option for BLD surgery, but further studies are needed to justify the introduction of RS in liver surgery and to define the type of patients that will benefit the most from it.
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Affiliation(s)
- Konstantinos Tsekouras
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Mamakos
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
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15
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The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-1265. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
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16
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Schlegel C, Zureikat AH. The Role of Simulation in Attaining Proficiency in Minimally Invasive Hepatopancreatobiliary Surgery. J Laparoendosc Adv Surg Tech A 2021; 31:561-564. [PMID: 33989062 DOI: 10.1089/lap.2021.0083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The implementation of robotic surgery in the field of hepato-pancreato-biliary (HPB) has been a slow but significant process. HPB procedures offer a unique challenge when for new technologies, as the surgeries themselves are complex, with long learning curves. Yet the benefits of the robotic approach for this patient population are notable: decreased length of stay, blood loss, postoperative complications, and improving quality of life. The use of robotic simulation focused curriculum plays a crucial role in mentoring experienced surgeons and surgical trainees. Although further study remains, early studies suggest a structured simulation curriculum decreases time, technical errors, and improves proficiency, ultimately leading to a more expedited and safe implementation of robotic techniques in the HPB field.
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Affiliation(s)
- Cameron Schlegel
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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17
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Guilbaud T, Fuks D, Berdah S, Birnbaum DJ, Beyer Berjot L. Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS). Surg Endosc 2021; 36:2321-2333. [PMID: 33871719 DOI: 10.1007/s00464-021-08507-w] [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: 12/02/2020] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). METHODS A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80. RESULTS A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). CONCLUSIONS The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France. .,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - Laura Beyer Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
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18
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Abstract
Minimally invasive liver surgery is safe and can be performed with results practically equal to those in open surgery. There are different techniques of parenchyma dissection and hemostasis available for the safe performance of minor and major resections, both laparoscopically and robotics based. Due to its technical options robotics-based surgery is a further development of laparoscopy. Expertise in minimally invasive and in liver surgery are essential prerequisites.
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Affiliation(s)
- Astrid Bauschke
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.
| | - Herman Kissler
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
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19
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Chiow AKH, Rho SY, Wee IJY, Lee LS, Choi GH. Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method. HPB (Oxford) 2021; 23:475-482. [PMID: 32863114 DOI: 10.1016/j.hpb.2020.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR. METHODS A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded. RESULTS A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities. CONCLUSION Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients.
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Affiliation(s)
- Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore
| | - Seoung Yoon Rho
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ian J Y Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lip Seng Lee
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore.
| | - Gi Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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20
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Mehren C, Korb W, Fenyöházi E, Iacovazzi D, Bernal L, Mayer MH. Differences in the Exposure of the Lumbar Nerve Root Between Experts and Novices: Results From a Realistic Simulation Pilot Study With Force Sensors. Global Spine J 2021; 11:224-231. [PMID: 32875893 PMCID: PMC7882829 DOI: 10.1177/2192568220917369] [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] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Nonrandomized prospective trial. OBJECTIVE Several studies could demonstrate "learning curves" in almost every single surgical procedure for unexperienced surgeons. This is in sharp contrast to the rising quality requirements in public health care to provide surgical training at patients "expense." The aim of this study was to visualize, measure, and set a baseline of the pressure load on the spinal nerve root during a simulated microdiscectomy on a standardized and validated model (RealSpine) under the influence of the level of surgical experience and individual skills. METHODS Five highly experienced spine surgeons and 5 trainees without considerable surgical experience were selected to perform a standardized microsurgical discectomy on a validated RealSpine simulator. Force-torque sensors were integrated in this simulator to measure the load on the nerve root. The forces were recorded every 125 ms. RESULTS We could identify cumulative for the total intervention as well as for defined single surgical steps of this procedure and as well in between the single subjects a significant higher tension and contusion forces on the nerve for the trainee group (Δp contusion 83-765 Nċs and Δp tension 159-1131 Nċs for the trainees. Δp contusion 16-171 Nċs and Δp tension 27-146 Nċs for the experts). CONCLUSION We could measure a difference between unexperienced and experienced surgeons regarding the manipulations of the nerve root during a standardized simulated microdiscectomy. This possibility could be the starting point for a new and innovative surgical education to improve outcome without negative side effects of "learning curves."
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Affiliation(s)
- Christoph Mehren
- Schön Klinik München Harlaching, Spine Center, Munich, Germany,Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria,Christoph Mehren, Schön Clinic Munich Harlaching, Harlachinger Straße 51, 81547 Munich, Germany.
| | - Werner Korb
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany,Vocationeers Salzburg, Hallein, Austria
| | - Esther Fenyöházi
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Davide Iacovazzi
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Luis Bernal
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Michael H. Mayer
- Schön Klinik München Harlaching, Spine Center, Munich, Germany,Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria
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21
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Takagi K, Kimenai HJAN, Terkivatan T, Tran KTC, Ijzermans JNM, Minnee RC. Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors. Int J Surg 2021; 86:7-12. [PMID: 33429077 DOI: 10.1016/j.ijsu.2020.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/23/2020] [Accepted: 12/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis. METHODS A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon. RESULTS Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN. CONCLUSIONS Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN.
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Affiliation(s)
- Kosei Takagi
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Hendrikus J A N Kimenai
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Turkan Terkivatan
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Khe T C Tran
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jan N M Ijzermans
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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22
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Is laparoscopic liver resection safe for intrahepatic cholangiocarcinoma? A meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 47:979-989. [PMID: 33339638 DOI: 10.1016/j.ejso.2020.11.310] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/23/2020] [Accepted: 11/30/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of laparoscopic liver resection for curative surgery of intrahepatic cholangiocarcinoma (ICC) is not well established. Herein, we perform a meta-analysis to compare the differences between laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC. METHODS Multiple electronic databases were searched and 8 relevant studies containing 552 patients treated by LLR and 2320 treated by OLR were identified. The fixed effects and a random-effects model were used to perform a meta-analysis. RESULTS Compared with OLR, LLR for ICC was associated with less blood transfusion (7.14% versus 17.11%; OR: 0.32; 95% CI 0.15 to 0.71; P < 0.05), higher R0 resection (85.63% versus 74.69%; OR: 1.48; 95% CI 1.13 to 1.95; P < 0.05), shorter length of stay (LOS) (SMD: -0.40; 95% CI -0.80 to 0.00; P = 0.05), less overall morbidities (20% versus 32.69%; OR: 0.50; 95% CI 0.33 to 0.78; P < 0.05), and less death due to tumor recurrence (22.39% versus 35.48%; OR: 0.50; 95% CI 0.29 to 0.86; P <0.05); but LLR was associated with smaller ICC, fewer major hepatectomies, less lymph node (LN) dissection rate, and inferior 5-year overall survival (OS) (P < 0.05). Duration of operation, blood loss, average LN retrieved, LN metastasis, major morbidities, mortality, tumor recurrence, 3-year OS and disease free survival (DFS), and 5-year DFS were comparable (P >0.05). CONCLUSION LLR for ICC is in the initial phase of exploration. More evidence is necessary to validate LLR for ICC.
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23
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Navarro JG, Kang I, Rho SY, Choi GH, Han DH, Kim KS, Choi JS. Major Laparoscopic Versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-Matched Analysis Based on Surgeons' Learning Curve. Ann Surg Oncol 2020; 28:447-458. [PMID: 32602059 DOI: 10.1245/s10434-020-08764-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis. METHODS This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized. RESULTS Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups. CONCLUSIONS LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.
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Affiliation(s)
- Jonathan Geograpo Navarro
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Surgical Oncology, Department of Surgery, Vicente Sotto Memorial Medical Center, Cebu City, Cebu, Philippines
| | - Incheon Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seoung Yoon Rho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Predictive ability of preoperative CT scan for the intraoperative difficulty and postoperative outcomes of laparoscopic liver resection. Surg Endosc 2020; 35:2942-2952. [PMID: 32556771 DOI: 10.1007/s00464-020-07734-x] [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: 04/08/2020] [Accepted: 06/09/2020] [Indexed: 12/07/2022]
Abstract
BACKGROUND The surgical difficulty and postoperative outcomes of laparoscopic liver resection (LLR) are related to the size of the cut liver surface. This study assessed whether the estimated parenchymal transection surface area could predict intraoperative difficulty and postoperative outcomes. METHODS LLRs performed between 2008 and 2018, for whom a preoperative CT scan was available for 3D review, were included in the study. The area of scheduled parenchymal transection was measured on the preoperative CT scan and cut-off values that could predict intraoperative difficulty were analyzed. RESULTS 152 patients who underwent left lateral sectionectomy (n = 27, median estimated area 30.1 cm2 [range 16.6-65.9]), left/right hepatectomy (n = 17 and n = 70, 76.8 cm2 [range 43.9-150.9] and 72.2 cm2 [range 39.4-124.9], respectively), right posterior sectionectomy (n = 7, 113.3 cm2 [range 102.1-136.3]), central hepatectomy (n = 11, 109.1 cm2 [range 66.1-186.1]) and extended left/right hepatectomy (n = 6 and n = 14, 115.3 cm2 [range 92.9-128.9] and 50.7 cm2 [range 13.3-74.9], respectively) were included. An estimated parenchymal transection surface area ≥ 100 cm2 was associated with significant increase in operative time (AUC 0.81, 95% CI [0.70, 0.93], p < 0.001) and estimated blood loss (AUC 0.92, 95% CI [0.86, 0.97], p < 0.001), as well as a higher conversion rate (22.2% vs. 4.0%, p < 0.001). Overall (p = 0.017) and major morbidity (p = 0.003), biliary leakage (p < 0.001) and pulmonary complications (p < 0.001) were significantly higher in patients with an estimated parenchymal transection surface area ≥ 100 cm2. CONCLUSIONS An estimated parenchymal transection surface area ≥ 100 cm2 is a relevant indicator of surgical difficulty and postoperative complications in LLR.
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Kabir T, Syn N, Goh BKP. Current status of laparoscopic liver resection for the management of colorectal liver metastases. J Gastrointest Oncol 2020; 11:526-539. [PMID: 32655931 PMCID: PMC7340801 DOI: 10.21037/jgo.2020.02.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.
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Affiliation(s)
- Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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