The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms

Improving the local excision strategy for rectal cancer after chemoradiotherapy: Surgical and oncological results

INTRODUCTION

Local excision (LE) for good responders after chemoradiotherapy (CRT) for rectal cancer is oncologically safe. Although the GRECCAR 2 trial did not demonstrate any advantages in morbidity, it provided useful information for optimising patient selection. This study assessed the impact of these results on our practice by focusing on the evolution of our selection criteria and management modalities for these patients over 10 years.

METHODS

Data were collected using our retrospective database of 110 patients who underwent LE after CRT for low and middle rectal cancer between 2010 and 2022 before (Group 1) and after (Group 2) consideration of the GRECCAR 2 trial results.

RESULTS

The pretherapeutic selection criteria remained stable after the GRECCAR 2 trial, although in Group 2, completion total mesorectal excision (TME) for ypT2 tumours with favourable tumour regression grade was abandoned, improving the organ preservation rate at 1 year from 63.3 % to 91.8 % (p < 0.01). The operative time and length of stay after LE were reduced by half in Group 2 (p < 0.01). The intention-to-treat rate for severe morbidity was also halved, but was not significant (8.2 % vs. 16.3 %, p = 0.24). Among patients with a 3-year follow-up data, disease-free survival was comparable between Group 1 (89.8 %) and Group 2 (85.4 %) (p = 0.51) with one locoregional recurrence in each group (2.0 % vs. 2.1 %, p = 1).

CONCLUSION

LE is a safe and effective strategy when performed in a "high-volume" centre. Improved methods for assessing tumour response and the selection criteria for completion TME enhanced surgical outcomes without compromising oncological outcomes.

Effect of virtual reality training to enhance laparoscopic assistance skills

BACKGROUND

While laparoscopic assistance is often entrusted to less experienced individuals, such as residents, medical students, and operating room nurses, it is important to note that they typically receive little to no formal laparoscopic training. This deficiency can lead to poor visibility during minimally invasive surgery, thus increasing the risk of errors. Moreover, operating room nurses and medical students are currently not included as key users in structured laparoscopic training programs.

OBJECTIVES

The aim of this study is to evaluate the laparoscopic skills of OR nurses, clinical medical postgraduate students, and residents before and after undergoing virtual reality training. Additionally, it aimed to compare the differences in the laparoscopic skills among different groups (OR nurses/Students/Residents) both before and after virtual reality training.

METHODS

Operating room nurses, clinical medical postgraduate students and residents from a tertiary Grade A hospital in China in March 2022 were selected as participants. All participants were required to complete a laparoscopic simulation training course in 6 consecutive weeks. One task from each of the four training modules was selected as an evaluation indicator. A before-and-after self-control study was used to compare the basic laparoscopic skills of participants, and laparoscopic skill competency was compared between the groups of operating room nurses, clinical medical postgraduate students, and residents.

RESULTS

Twenty-seven operating room nurses, 31 clinical medical postgraduate students, and 16 residents were included. The training course scores for the navigation training module, task training module, coordination training module, and surgical skills training module between different groups (operating room nurses/clinical medical postgraduate/residents) before laparoscopic simulation training was statistically significant (p < 0.05). After laparoscopic simulation training, there was no statistically significant difference in the training course scores between the different groups. The surgical level scores before and after the training course were compared between the operating room nurses, clinical medical postgraduate students, and residents and showed significant increases (p < 0.05).

CONCLUSION

Our findings show a significant improvement in laparoscopic skills following virtual surgery simulation training across all participant groups. The integration of virtual surgery simulation technology in surgical training holds promise for bridging the gap in laparoscopic skill development among health care professionals.

Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute

INTRODUCTION

Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications.

MATERIALS AND METHODS

All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted.

RESULTS

Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%.

CONCLUSION

This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.

Transanal minimally invasive surgery - A single-center experience

Background

Transanal minimally invasive surgery (TAMIS) was described in the literature 10 years ago. This procedure requires laparoscopic technical skills. It has been well accepted widely worldwide. TAMIS has been applied to multiple procedures, including excision for rectal polyps and cancer, with acceptable outcomes. The study aimed to assess the outcomes of TAMIS in a large district general hospital.

Methodology

A retrospective study on prospectively collected data on 52 consecutive patients of TAMIS performed in a single unit was conducted between May 2014 and February 2020. Data were collected on patient demographics, clinical diagnosis, peri-operative findings, pathological findings, adequacy of excision and complications. Patients were followed up as per the trust and national post-polypectomy guidelines.

Results

Among the 52 patients, TAMIS procedures were completed in 50 patients, of which 31 were female. The procedure was successful in 96.5% but had to abandon in two cases. There was no conversion to another procedure. Pre-operative indications were rectal polyps and one case was an emergency TAMIS in a patient who was bleeding following incomplete colonoscopic polypectomy. The final histology reported that the majority were benign polyps (46), and only 11 cases were malignant. The median distance of the lesion from the anal verge was 6 cm (3-10 cm). The median operative time was 55 min (8-175 min). A total of 45 (77.5%) lesions were completely excised and had negative microscopic margins. Most patients (64%) were discharged home the same day. No complications were observed at a median follow-up of 20 months (6-48 months). There was no mortality.

Conclusions

Our data suggest that TAMIS can be safely performed in a district general hospital for both benign and early rectal cancer. TAMIS was also able to control post-polypectomy bleeding and completion of rectal polypectomy. In selected cases, day-case TAMIS is safe and feasible.

Assessment of the learning curve for the novel transanal minimally invasive surgery simulator model

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is technically demanding and requires extensive training. We developed the TAMIS simulator model by remodeling an existing laparoscopic training system to educate trainees and analyzed their learning curves.

METHODS

Between March 2020 and June 2020, 12 trainees performed TAMIS simulator training sessions. The total operative time, including specimen removal and wound closure, was recorded. The wound closure and specimen quality, trainee self-confidence, and supervisor evaluation of technical performance were documented. A moving average was used to analyze the number of training sessions required to stabilize the procedure time, while a cumulative sum analysis was performed to identify that required to reach proficiency with each item.

RESULTS

Each trainee completed 20 TAMIS simulator training sessions. The median total procedure time was 13 min (range, 4-60 min), which stabilized after 15 training sessions. The median times for specimen removal and wound closure were 3 min (range, 1-18 min) and 10 min (range, 2-50 min), respectively, which stabilized after 7 and 15 training sessions, respectively. The mean specimen and wound closure quality scores were 2.9 ± 0.9 (on a scale from 1 to 4) and 2.3 ± 1.1 (on a scale from 1 to 4), respectively, competencies in which were achieved after 16 and 20 training sessions, respectively. The mean trainee self-confidence and supervisor evaluation of technical performance scores were 2.4 ± 1.2 (on a scale from 1 to 5) and 2.7 ± 1.2 (on a scale from 1 to 5), respectively, competencies in which were achieved after 20 and 17 training sessions, respectively.

CONCLUSION

Trainees required 15 training sessions to stabilize the procedure time and 16-20 training sessions to demonstrate competencies with the TAMIS simulator model. We expect this simulator model may help surgeons more rapidly acquire the skills required for TAMIS.

Transanal Endoscopic Surgery: Who Should Be Doing This Procedure?

Transanal endoscopic surgery (TES) was introduced in the 1980s, but more widely adopted in the late 2000s with innovations in instrumentation and training. Moreover, the global adoption of minimally invasive approaches to abdominal procedures has led to translatable skills for TES among colorectal and general surgeons. While there are similarities to laparoscopic surgery, TES has unique challenges related to the narrow confines of intraluminal surgery, angled instrumentation, and relatively uncommon indications limiting the opportunity to practice. The following review discusses the current evidence on TES learning curves, including potential limitations related to the broad adoption of TES by general surgeons. This article aims to provide general recommendations for the safe expansion of TES.

Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons

Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.

Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision

There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer-transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)-have a distinct learning curve for competence in the procedures, and require special training for familiarity with the "bottom-up" anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.

Transanal Minimally Invasive Surgery: An Effective Approach for Patients Who Require Redo Pelvic Surgery for Anastomotic Failure

BACKGROUND

Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery.

OBJECTIVE

This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary-care institution.

PATIENTS

Consecutive patients undergoing transanal minimally invasive redo proctectomy were included.

INTERVENTIONS

Transanal minimally invasive redo proctectomy was performed.

MAIN OUTCOME MEASURES

The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution.

RESULTS

Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months.

LIMITATIONS

This study was limited by its small sample size and its single-institution focus.

CONCLUSION

For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.

Individual learning curve of cytoreductive surgery for peritoneal metastasis from colorectal cancer: A process with an impact on survival

BACKGROUND

This study aimed to assess the learning curve (LC) of cytoredutive surgery (CRS) of peritoneal metastasis (PM) from colorectal cancer (CRC). Information about learning curves is important for developing teaching tools and well-structured training programs for the implementation of this complex procedure in new healthcare centers. The aim of this study was to estimate how many procedures an inexperienced surgeon must perform (the length of the learning period) in order to demonstrate an acceptably low rate of locoregional recurrence.

METHODS

All consecutive 74 patients with CRS for CRC performed by a novice surgeon between 2012 and 2017 in a tertiary cancer center were included. The learning curve was calculated by a cumulative sum control chart (CUSUM) graph. Two groups were formed based on the length of the learning period and were compared on overall and disease free survival.

RESULTS

The risk of locoregional recurrence decreased after surgeons had performed 19 cases, suggesting a learning period of this length. Overall survival and postoperative morbidity were not significantly different between learning and proficiency periods. Multiple linear regression analysis showed that the learning period and peritoneal cancer index are the only factors affecting disease free survival. A second learning period was observed in cases where patient care became more complex.

CONCLUSIONS

This study confirms that learning period has negative impacts on disease-free survival. An initial experience supervised in specialized centers allow to have a short learning curve for CRS for peritoneal metastases for CRC.

Novel box trainer for taTME - prospective evaluation among medical students

Background

Transanal total mesorectal excision (taTME) has been subject to extensive research and increasing clinical application. It allows further reduction of trauma by accessing via a natural orifice. Manifold platforms and instruments have been introduced and heterogeneity in surgical techniques exists. Because of the technique’s complexity there is a persistent need for dedicated training devices and concepts.

Materials and methods

The key steps of taTME were analyzed and a box trainer with three modules resembling these steps was designed and manufactured. Twenty-one surgically inexperienced medical students performed five repetitions of the three tasks with the new box trainer. Time and error count were analyzed for assessment of a learning curve.

Results

A significant reduction of processing time could be demonstrated for tasks 1–3 (p < 0.001; p < 0.001; p = 0.001). The effect size was high for comparison of repetition 1 and 5 and decreased over the course (task 1: r = 0.88 vs. r = 0.21; task 2: r = 0.86 vs. r = 0.23; task 3: r = 0.74 vs. r = 0.44). Also, a significant reduction of errors was demonstrated for tasks 1 and 2. The decrease of effect size was analogously demonstrated.

Conclusions

The trainer might help to reduce the use of animal models for testing of platforms and instruments as well as gaining first-hand experience in transanal rectal resection.

TAMIS is a valuable alternative to TEM for resection of intraluminal rectal tumors

BACKGROUND

The aim of this study was to compare the short-term outcome after Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS) for intraluminal rectal lesions.

METHODS

Retrospective analysis of a prospectively maintained database of all TEM and TAMIS procedures performed at a single institution by one surgeon between March 2009 and September 2017 was conducted. Primary outcome was operating time. Secondary outcomes were blood loss, pathological outcome, length of hospital stay, 30-day readmission and mortality.

RESULTS

Fifty-three patients underwent TEM procedure and 68 patients underwent TAMIS. Operating time was significantly shorter for TAMIS compared with TEM (median 45 vs 65 min, p < 0.0001). Blood loss was negligible for both TEM and TAMIS. Resection margins, lesion grade and invasion depth were comparable for both approaches. A significantly higher postoperative readmission rate was observed in the TEM group (17% vs 4.4%, p = 0.031). Mortality was zero in both groups.

CONCLUSIONS

TAMIS is a valuable alternative to TEM, leading to decreased operating times, because all resections can be done in lithotomy position.