Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy?

Defining operative experience targets in surgical training: A systematic review

BACKGROUND

The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence.

METHODS

A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model.

RESULTS

Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b).

CONCLUSION

Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training.

Single site versus conventional laparoscopic appendectomy: some pain for no gain?

INTRODUCTION

The optimal laparoscopic appendectomy approach is not clear, comparing single site laparoscopic appendectomy (SILA) to conventional 3-port appendectomy (CLA). We investigated outcomes in pediatric patients comparing SILA to CLA: length of operation, length of stay, time to resumption of regular diet, follow up, rehospitalization, and cost.

METHODS

Data was collected from children 1 to 18 years with appendectomy at Loma Linda University from 2018 to 2020, operated by two surgeons. Analysis utilized two-sample T, chi-squared, and Fisher's exact tests.

RESULTS

Of 173 patients, 77 underwent SILA and 96 had CLA. There was no gender, age, or race difference between groups. Mean WBC was 17.5 × 10³/mL in SILA group, compared to 15.3 × 10³/mL in CLA group (P = 0.004). Operative time was 47.0 SILA compared to 49.5 minutes CLA (P = 0.269). Of SILA cases, 55.8% were simple appendicitis, while 53.3% of the CLA cases were simple (P = 0.857). Regular diet was resumed after 1.7 days in the SILA group, 1.1 days in CLA (P = 0.018). Length of stay was 2.9 days for SILA, 2.4 days for CLA (P = 0.144). Seven children required hospital readmission, 5 SILA and 2 CLA (P = 0.244). Five of the children who returned had intra-abdominal abscesses, of whom 4 had SILA. There was no difference in cost.

CONCLUSIONS

The operative techniques had similar outcomes and operative times. There was a trend toward more intra-abdominal abscesses in the SILA group. Further study and longer follow up is needed to determine if there is an advantage to one laparoscopic approach over another.

Differences in mental workload between traditional and single-incision laparoscopic procedures measured with a secondary task

INTRO

The mental workload associated with laparoscopic suturing can be assessed with a secondary task that requires the same visual-spatial attentional resources. The purpose of this study was to use a secondary task to measure the incremental workload demands of single-incision laparoscopic surgery (SILS) procedures versus traditional laparoscopic procedures.

METHOD

12 surgery residents and surgical assistants who had met FLS criteria on an FLS and SILS simulator performed one trial each of peg transfer, cutting, and intracorporeal suturing tasks simultaneously with the secondary task and provided subjective workload ratings using the NASA-TLX.

RESULTS

SILS procedures resulted in lower primary and secondary task scores, p < 0.001 and higher workload ratings, p < 0.0001. Suturing resulted in lower primary (p < 0.003) and secondary task scores (p < 0.017) and higher workload ratings (p < 0.017) compared to the other tasks.

CONCLUSIONS

SILS procedures were significantly more mentally demanding than traditional laparoscopic procedures corroborated by primary and secondary tasks scores and subjective ratings.

Competence acquisition for single-incision laparoscopic cholecystectomy

Background and Objectives:

Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy.

Methods:

We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency.

Results:

Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%.

Conclusions:

Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Impact of Experience on Quality Outcomes in Single-incision Cholecystectomy in Children

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe in children; however, factors that impact outcomes are not well understood. We report a retrospective review of 151 patients who underwent SILC between 2009 and 2013. Regression analysis was used to determine inflection of learning curve. Patients were grouped by early cases, late cases, and late case with surgical trainees. Mean age for all patients was 15 ± 3 years (5–20.5 year), and mean weight was 66.5 ± 21.3 kg (15–117 kg). There was a decrease in operative times between the early group (n = 15) and the late group (n = 100) (75.3 vs 56.1 minutes, P < 0.05). Surgical trainees were involved in 36 cases, and their introduction did not significantly increase operative times (56.1 vs 60.4 minutes, P = NS (Non-significant)). No difference in operative times between early cases and cases with trainees was identified (75.3 vs 60.4 minutes, P = NS). The complication was 6 per cent, with no significant differences between the groups. There were five conversions (3.3%). During the adoption of SILC, significantly decreased operative times were achieved after a short learning curve, and these were maintained with surgical trainees. Our results show that SILC can be safely introduced into a pediatric surgical practice.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes.

METHODS

A retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis.

RESULTS

SILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups.

CONCLUSION

The adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

Impact of fellowship during single-incision laparoscopic cholecystectomy

Adoption of single-incision laparoscopic cholecystectomy during fellowship training is safe and feasible; however, longer operative times are expected during the teaching process.

Background and Objectives:

Minimally invasive surgery fellowship programs have been created in response to advancements in technology and patient's demands. Single-incision laparoscopic cholecystectomy (SILC) is a technique that has been shown to be safe and feasible, but this appears to be the case only for experienced surgeons. The purpose of this study is to evaluate the impact of minimally invasive surgery fellow participation during SILC.

Methods:

We reviewed data from our experience with SILC during 3 years. The cases were divided in two groups: group 1 comprised procedures performed by the main attending without the presence of the fellow, and group 2 comprised procedures performed with the fellow present during the operation. Demographic characteristics, comorbidities, indication for surgery, total surgical time, hospital length of stay, and complications were evaluated.

Results:

The cohort included 229 patients: 142 (62%) were included in group 1 and 87 (38%) in group 2. No differences were found in demographic characteristics, comorbidities, and indication for surgery between groups. The total surgical time was 34.4 ± 11.4 minutes for group 1 and 46.8 ± 16.0 minutes for group 2 (P < .001). The hospital length of stay was 0.89 ± 0.32 days for group 1 and 1.01 ± 0.40 days for group 2 (P = .027). No intraoperative complications were seen in either group. There were 3 postoperative complications (2.1%) in group 1 and none in group 2 (P = .172).

Conclusion:

Adoption of SILC during an established fellowship program is safe and feasible. A longer surgical time is expected during the teaching process.

Fluorescence-guided surgery with live molecular navigation--a new cutting edge

A glowing new era in cancer surgery may be dawning. Using fluorescently labelled markers, surgical molecular navigation means that tumours and nerves can be displayed in real time intra-operatively in contrasting pseudocolours, which allows more complete tumour resection while preserving important structures. These advances can potentially cause a paradigm shift in cancer surgery, improving patient outcome and decreasing overall health-care costs.

Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms

BACKGROUND

Many series have shown the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of single-incision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches.

METHODS

The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System.

RESULTS

The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%).

CONCLUSIONS

The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.