When can I be proficient in laparoscopic surgery? A systematic review of the evidence

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease

BACKGROUND

Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention.

METHODS

All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed.

RESULTS

There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%).

CONCLUSION

Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications.

TYPE OF STUDY

Original research, retrospective cohort.

LEVEL OF EVIDENCE

III.

The Impact of Surgical Telementoring on Reducing the Complication Rate in Endoscopic Endonasal Surgery of the Skull Base

BACKGROUND

Pituitary adenomas represent the most common pituitary disorder, with an estimated prevalence as high as 20%, and they can manifest with hormone hypersecretion or deficiency, neurological symptoms from mass effect, or incidental findings on imaging. Transsphenoidal surgery, performed either microscopically or endoscopically, allows for a better extent of resection while minimising the associated risk in comparison to the transcranial approach. Endoscopy allows for better visualisation and improvement in tumour resection with an improved working angle and less nasal morbidity, making it likely to become the preferred surgical treatment for pituitary neoplasms. The learning curve can be aided by telementoring.

METHODS

We retrospectively analysed the clinical records of 94 patients who underwent an endoscopic endonasal resection of a pituitary neoplasm between the years 2011 and 2023 at Maribor University Medical Centre in Slovenia. Remote surgical telementoring over 3 years assisted with the learning curve.

RESULTS

The proportion of complication-free patients significantly increased over the observed period (60% vs. 79%). A gradual but insignificant increase in the percentage of patients with improved endocrine function was observed. Patients' vision improved significantly over the observed period. By gaining experience, the extent of gross total tumour resection increased insignificantly (67% vs. 79%).

CONCLUSIONS

Telementoring for the endoscopic endonasal approach to pituitary neoplasms enables low-volume centres to achieve efficiency, decreasing rates of postoperative complications and increasing the extent of tumour resection.

From Novice to Mastery: Learning Curve and Efficacy Analysis of Short-Term Spinal Cord Stimulation for Diabetic Foot Ulcers

BACKGROUND

To analyze the learning curve of novices in mastering short-term Spinal cord stimulation (st-SCS) for diabetic foot, evaluating the efficacy, safety, and difficulty of this technique.

METHODS

A retrospective review of diabetic foot patients treated with st-SCS at our hospital was conducted. All procedures were performed by the same physician and patients were sequentially numbered according to the order of surgery. Learning curves were plotted using segmented linear regression and cumulative sum curves based on surgery duration. Patients were divided into 2 groups according to the inflection points on the learning curve: the learning group and the mastery group. Pre- and postoperative efficacy indicators were recorded and compared, along with general patient data, perioperative parameters, and incidence of complications.

RESULTS

A total of 36 patients were included. Significant improvements were observed post-st-SCS in ulcer size (from 7.00 cm2 to 4.00 cm2), visual analog scale (from 7.00 to 3.00), foot temperature (from 30.06°C to 32.37°C), and Pittsburgh Sleep Quality Index (from 14.42 to 8.36) (P < 0.05). The physician could proficiently perform st-SCS after 9 cases. Surgery time was significantly shorter in the mastery group (1-9 cases) compared to the learning group (10-36 cases) (28.04 vs. 43.56 min, P < 0.05). There were no significant differences between the 2 groups in baseline data, improvement in efficacy indicators, or complications (P > 0.05).

CONCLUSIONS

St-SCS is beneficial for wound healing, pain relief, improving peripheral circulation, and improving sleep quality. Surgeons can master this simple and safe technique in about 9 cases.

Confronting new challenges: Faculty perceptions of gaps in current laparoscopic curricula in a changing training landscape

Background

Opportunities for residents to develop laparoscopic skills have decreased with the rise in robotic operations and the development of complex, subspecialized laparoscopic operations. Given the changing training landscape, this study aimed to identify laparoscopic surgeons' perceptions of gaps in current laparoscopic skills in general surgery, obstetrics-gynecology, and urology residency programs.

Methods

Laparoscopic surgeons who operate with residents participated in semi-structured interviews. Questions addressed expectations for resident proficiency, deficits in laparoscopic surgical skills, and barriers to learning and teaching. Two authors independently coded de-identified transcripts followed by a conventional content analysis.

Results

Fourteen faculty members from thirteen subspecialties participated. Faculty identified three main areas to improve laparoscopic training across specialties: foundational knowledge, technical skills, and cognitive skills. They also recognized an overarching opportunity to address faculty development.

Conclusions

This qualitative study highlighted key deficiencies in laparoscopic training that have emerged in the current, changing era of minimally invasive surgery.

Key message

This qualitative study identified laparoscopic educators' perceptions of deficiencies in laparoscopic training. Findings emphasized the importance of incorporating high quality educational practices to optimize training in the current changing landscape of laparoscopic surgery.

Enhanced Recovery after Surgery Applied to Pediatric Laparoscopic Cholecystectomy for Simple Cholelithiasis: Feasibility and Teaching Insights

BACKGROUND

Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients.

METHODS

In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees.

RESULTS

Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9-18), and the median duration of surgery was 54 min (IQR 13-145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified.

CONCLUSIONS

These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons.

LEVEL OF EVIDENCE

Level III.

Percutaneous Transforaminal Endoscopic Discectomy Learning Curve: A CuSum Analysis

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To describe the learning curve for percutaneous transforaminal endoscopic discectomy (PTED) and demonstrate its efficacy in treating lumbar disc herniation.

SUMMARY OF BACKGROUND DATA

The learning curve for PTED has not yet been standardized in the literature.

PATIENTS AND METHODS

Consecutive patients who underwent lumbar PTED by a single surgeon between December 2020 and 2022 were included. Cumulative sum analysis was applied to operative and fluoroscopy time to assess the learning curve. Inflection points were used to divide cases into early and late phases. The 2 phases were analyzed for differences in operative and fluoroscopy time, length of stay, complications, and patient-reported outcome measures (PROMs). Patient characteristics and operative levels were also compared. PROMs entailed the Oswestry Disability Index, Patient-Reported Outcomes Measurement Information System, Visual Analog Scale Back/Leg, and 12-item Short Form Survey at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) time points. PROMs between PTED cases and a comparable cohort of tubular microdiscectomy cases, performed by the same surgeon, were compared.

RESULTS

Fifty-five patients were included. Cumulative sum analysis indicated that both operative and fluoroscopy time diminished rapidly after case 31, suggesting a learning curve of 31 cases (early phase: n = 31; late phase: n = 24). Late-phase cases exhibited significantly lower operative times (85.7 vs . 62.2 min, P = 0.001) and fluoroscopy times (131.0 vs . 97.2 s, P = 0.001) compared with the early-phase cases. Both early and late-phase cases showed significant improvement in all PROMs. There were no differences in PROMs between the patients who underwent PTED and tubular microdiscectomy.

CONCLUSION

The PTED learning curve was found to be 31 cases and did not impact PROMs or complication rates. Although this learning curve reflects the experiences of a single surgeon and may not be broadly applicable, PTED can serve as an effective modality for the treatment of lumbar disc herniation.

Introduction of paediatric laparoscopic cholecystectomy in Scotland: a national review of incidence, outcomes and training implications

BACKGROUND

We present a national data series to determine the incidence, outcomes and training opportunities for laparoscopic cholecystectomy among children <16yrs in Scotland as performed by paediatric surgeons.

METHODS

A retrospective cohort study was performed reviewing laparoscopic cholecystectomy performed at the three children's hospitals in Scotland. Using the National Records Scotland Database mid-year population estimates; age and sex specific annual incidence rates of laparoscopic cholecystectomy were calculated between 1998-2015. Trends in the observed case mix were tested using univariate linear regression and students t-test.

RESULTS

Between 1998-2015; 141 paediatric laparoscopic cholecystectomies were performed. The annual rate of cholecystectomy increased from 0.10/100,000 to 0.88/100,000 (p = 0.069). Sex specific incidences were identified; 0.00-0.90/100,000 (p = 0.098) in girls and 0.20-0.86/100,000 in boys (p = 0.28). Cholecystectomy was more frequent in girls (63%; p = 0.04). No major complications, defined as common bile duct injury or mortality were identified. Overall; 75% of cases were performed by consultants (n = 17 consultants, median = 5 cases, p < 0.05) and 25% by trainees.

CONCLUSION

We have demonstrated that despite a low national case load (8 laparoscopic cholecystectomies per year) paediatric surgeons have been able to perform laparoscopic cholecystectomy safely without major morbidity.

Learning curve of percutaneous endoscopic transforaminal lumbar discectomy by a single surgeon

To evaluate the learning curve of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) from the novice stage to the proficient stage, we performed retrospective study for patients with lumbar disc herniation who underwent PETLD performed by a single surgeon and evaluated the surgeon's learning curve and the effect of surgical proficiency on outcomes.A total of 48 patients who underwent PETLD at the lower lumbar level (L3-S1) with a minimum 1-year follow-up were enrolled. The learning curve of the surgeon was assessed using cumulative study of operation time and linear regression analyses to reveal the correlation between operation time and case series number.Because the cutoff of familiarity was 25 cases according to the cumulative study of operation time, the patients were allocated into two groups: early group (n = 25) and late group (n = 23). The clinical, surgical, and radiological outcomes were retrospectively evaluated and compared between the two groups.According to linear regression analyses, the operation time was obtained using the following formula: operation time (minutes) = 69.925-(0.503 × [case number]) (P < .001).As expected, the operation time was significantly different between the two groups (mean 66.00 ± 11.37 min in the early group vs 50.43 ± 7.52 min in the late group, P < .001). No differences were found between the two groups in demographic data and baseline characteristics. Almost all clinical outcomes (including pain improvement and patient satisfaction), surgical outcomes (including failure, recurrence, and additional procedure rates), and radiological outcomes (including change of disc height and sagittal angles) did not differ between the two groups.However, the late group demonstrated a more favorable postoperative volume index of the remnant disc (362.91 mm3 [95% confidence interval, 272.81-453.02] in the early group vs 161.14 mm3 [95% confidence interval, 124.31-197.97] in the late group, P < .001), and a lower complication rate related to exiting nerve root (16.0% in the early group vs 0% in the late group, P = .045).The learning curve of PETLD is not as difficult as that of other minimally invasive spine surgery technique. Although the overall outcomes were not different between the groups, the risks of incomplete decompression and exiting root injury-related complication were higher in the novice stage.

Learning curve of trans-sacral epiduroscopic laser decompression in herniated lumbar disc disease

BACKGROUND

Trans-sacral epiduroscopic laser decompression (SELD) using slender epiduroscope and a holmium YAG laser is one of the minimally invasive surgical options for lumbar disc herniation. However, the learning curve of SELD and the effect of surgical proficiency on clinical outcome have not yet been established. We investigated patients with lumbar disc herniation undergoing SELD to report the clinical outcome and learning curve.

METHODS

Retrospective analysis of clinical outcome and learning curve were performed at a single center from clinical data collected from November 2015 to November 2018. A total of 82 patients who underwent single-level SELD for lumbar disc herniation with a minimum follow-up of 6.0 months were enrolled. Based on the findings that the cut-off of familiarity was 20 cases according to the cumulative study of operation time, patients were allocated to two groups: early group (n = 20) and late group (n = 62). The surgical, clinical, and radiological outcomes were retrospectively evaluated between the two groups to analyze the learning curve of SELD.

RESULTS

According to linear and log regression analyses, the operation time was obtained by the formula: operation time = 58.825-(0.181 × [case number]) (p < 0.001). The mean operation time was significantly different between the two groups (mean 56.95 min; 95% confidence interval [CI], 49.12-64.78 in the early group versus mean 45.34 min; 95% CI, 42.45-48.22 in the late group; p = 0.008, non-parametric Mann-Whitney U test). Baseline characteristics, including demographic data, clinical factors, and findings of preoperative magnetic resonance imaging, did not differ between the two groups. Also, there was no significant difference in terms of surgical outcomes, including complication and failure rates, as well as clinical and radiological outcomes between the two groups.

CONCLUSION

The learning curve of SELD was not as steep as that of other minimally invasive spinal surgery techniques, and the experience of surgery was not an influencing factor for outcome variation.

Quantitative and individualized assessment of the learning curve in preoperative planning of the acetabular cup size in primary total hip arthroplasty

INTRODUCTION

The aim of the present study was to investigate the learning curves of 2 trainees with different experience levels to reach proficiency in preoperative planning of the cup size based on learning curve cumulative summation (LC-CUSUM) statistics and a cumulative summation (CUSUM) test.

MATERIALS AND METHODS

One-hundred-twenty patients who had undergone primary total hip arthroplasty with a cementless cup were selected. Preoperative planning was performed by an experienced orthopedic surgeon. Trainee 1 (student) and trainee 2 (resident) planned the cup size. The trainees were blinded to the preoperative plan and the definitive cup size. Only after a cup size was chosen, the trainees were unblinded to the preoperative plan of the surgeon. LC-CUSUM was applied to both trainees to determine when proficiency in determining the appropriate cup size was reached. A CUSUM test was applied to ensure retention of proficiency.

RESULTS

With reference to the preoperative plan of the surgeon, LC-CUSUM indicated proficiency after 94 planning attempts for trainee 1 and proficiency after 66 attempts for trainee 2, respectively. Trainee 1 and 2 maintained proficiency thereafter. With reference to the definitive cup size, LC-CUSUM did not signal competency within the first 120 planning attempts for trainee 1. Trainee 2 was declared competent after 103 attempts and retained competency thereafter.

CONCLUSIONS

LC-CUSUM/CUSUM allow for an individualized, quantitative and continuous assessment of planning quality. Based on LC-CUSUM statistics, the two trainees of this study gain proficiency in planning of the acetabular cup size after 50-100 attempts when an immediate feedback is provided. Previous experience positively influences the performance. The study serves as basis for the medical education of students and residents in joint replacement procedures.

Impact of ultrasound guided training in the diagnosis of the fetal head position during labor: A prospective observational study

OBJECTIVES

To assess whether the additional training with transabdominal ultrasound may improve the accuracy of the transvaginal digital examination in the assessment of the fetal head position during the active stage of labor.

METHODS

Prospective observational study involving 2 residents in their 1 st year of training in Obstetrics with no prior experience in neither transvaginal digital examination nor ultrasound. Women with term, cephalic presenting fetus and active labor with cervical dilation ≥ 8 cm and ruptured membranes were included. In the preliminary phase of the study, the resident A ("blinded") was assigned to assess the fetal head position by transvaginal digital examination, while the resident B ("unmasked") performed transvaginal digital examination following transabdominal ultrasound, which was considered to be the gold standard to determine the fetal head position. After 50 examinations independently performed by each resident in the training phase, a post-training phase of the study was carried out to compare the accuracy of each resident in the diagnosis of fetal head position by digital assessment. The occiput position was eventually confirmed by ultrasound performed by the main investigator.

RESULTS

Over a 6 months period, 90 post-training vaginal examinations were performed by each resident. The number of incorrect diagnoses of head position was higher for the "blinded" resident compared with the "unmasked" resident subjected to the ultrasound training (28/90 or 31.1 % vs 15/90 or 16.7 % p = 0.02). For both residents a wrong diagnosis was more likely with non-OA vs OA fetuses but this difference was statistically significant for the "blinded" Resident (10/20 or 50 % vs 18/70 or 25.7 % p = 0.039) but not for the "unmasked" Resident (5/18 or 27.9 % vs 10/72 or 13.9 % p = 0.16).

CONCLUSION

The addition of transabdominal ultrasound as a training tool in the determination of the fetal head position during labor seems to improve the accuracy of the transvaginal digital examination in unexperienced residents.

Quality-based assessment of camera navigation skills for laparoscopic fundoplication

Laparoscopic fundoplication is considered the gold standard surgical procedure for the treatment of symptomatic hiatus hernia. Studies on surgical performance in minimally invasive hiatus hernia repair have neglected the role of the camera assistant so far. The current study was designed to assess the applicability of the structured assessment of laparoscopic assistance skills (SALAS) score to laparoscopic fundoplication as an advanced and commonly performed laparoscopic upper GI procedure. Randomly selected laparoscopic fundoplications (n = 20) at a single institute were evaluated. Four trained reviewers independently assigned SALAS scoring based on synchronized video and voice recordings. The SALAS score (5-25 points) consists of five key aspects of laparoscopic camera navigation as previously described. Experience in camera assistance was defined as at least 100 assistances in complex laparoscopic procedures. Nine different surgical teams, consisting of five surgical residents, three fellows, and two attending physicians, were included. Experienced and inexperienced camera assistants were equally distributed (10/10). Construct validity was proven with a significant discrimination between experienced and inexperienced camera assistants for all reviewers (P < 0.05). The intraclass correlation coefficient of 0.897 demonstrates the score's low interrater variability. The total operation time decreases with increasing SALAS score, not reaching statistical significance. The applied SALAS score proves effective by discriminating between experienced and inexperienced camera assistants in an upper GI surgical procedure. This study demonstrates the applicability of the SALAS score to a more advanced laparoscopic procedure such as fundoplication enabling future investigations on the influence of camera navigation on surgical performance and operative outcome.

Learning curve of percutaneous endoscopic interlaminar lumbar discectomy versus open lumbar microdiscectomy at the L5-S1 level

Objective

Many studies on the clinical outcome of full endoscopic spine surgery versus open spine surgery have been published. However, only a few studies have compared the learning curves of percutaneous endoscopic interlaminar lumbar discectomy (PEILD) and open lumbar microdiscectomy (OLM) at the L5–S1 level. This study included patients with disc herniation at the L5–S1 level, who underwent PEILD or OLM performed by a single novice surgeon and compared the learning curves.

Methods

Fifty-six patients who underwent PEILD or OLM at the L5–S1 level and completed a minimum 1-year follow-up were enrolled in the study. The patients were allocated to the PEILD group (n = 27, September 2014 to August 2016) or an OLM group (n = 29, September 2012 to August 2014). The learning curves were retrospectively compared based on operation time and surgical outcomes, including complication, failure, and recurrence rates were retrospectively compared.

Results

Significant intergroup differences were not noted with respect to the baseline characteristics, including age, sex, body mass index, preoperative symptoms, or preoperative radiological findings. The mean operation time was significantly shorter in the PEILD group than in the OLM group (63.89±17.99 min versus 78.03±19.01 min, p = 0.006). Based on the operation time according to the number of cases, the learning curve was more difficult in the PEILD group according to the cumulative analysis (case number cut-off for proficiency was 18 in the PEILD group versus 10 in the OLM group) and linear regression analysis (proportionality constant for decrease in the operation time was -0.922 in the PEILD group versus -1.738 in the OLM group) than that in the OLM group. However, the surgical outcomes, including failure, surgical efficacy based on nerve root decompression, complication, and recurrence rates did not differ between the two groups.

Conclusion

Although the learning curve of PEILD was more difficult than that of OLM, the mean operation time was shorter in the PEILD group than that in the OLM group. Moreover, based on the surgical outcomes, PEILD showed efficacy and safety similar to those of OLM.

Learning Curve for Percutaneous Endoscopic Lumbar Diskectomy in Bi-needle Technique Using Cumulative Summation Test for Learning Curve

BACKGROUND

The purpose of this study was to determine the number of cases needed to achieve the level of competence for percutaneous endoscopic lumbar diskectomy (PELD) via the bi-needle technique using the cumulative summation test for learning curve (LC-CUSUM).

METHODS

A retrospective design was used. We included 60 patients who underwent a single-level PELD via the bi-needle technique performed by a single surgeon. The surgeon had 5 years of experience in open surgery including the transforaminal endoscopic spine system and Yeung endoscopic spine system but no experience in the bi-needle technique. Surgery success was defined as an operative time <60 minutes, and the acceptable procedure was completed within 3 times of C-arm fluoroscopies. The LC-CUSUM was used to analyze the data.

RESULTS

The average operative time for PELD via the bi-needle technique was 58.3 ± 12.4 minutes. The mean operative time was 65.7 ± 12.1 minutes in the early learning period (30 cases) and 51.0 ± 7.5 minutes in the late learning period (30 cases) (P < 0.05). On the basis of the evaluation indexes of the operative time and radioactive exposure, the LC-CUSUM signaled proficiency for the bi-needle technique at the 50th-54th operation. Seven cases of complications were observed during the whole learning process, with 6 in the early period and 1 in the late period (P < 0.05).

CONCLUSIONS

The novel bi-needle technique is safe and effective for PELD with appropriate patients, and the learning curve is acceptable. A substantial learning period (50-54 cases) is needed before a spine surgeon can master the bi-needle technique.

Impact of center volume and the adoption of laparoscopic donor nephrectomy on outcomes in pediatric kidney transplantation

Reports for pediatric kidney transplant recipients suggested better outcomes for ODN compared to LDN. Contemporary outcomes stratified by donor type and center volume have not been evaluated in a national dataset. UNOS data (2000-2014) were analyzed for pediatric living donor kidney transplant recipients. The primary outcome was GF; secondary outcomes were DGF, rejection, and patient survival. Live donor nephrectomies for pediatric recipients decreased 30% and transitioned from ODN to LDN. GF rates did not differ for ODN vs LDN (P = .24). GF was lowest at high volume centers (P < .01). Donor operative approach did not contribute to GF. LDN was associated with less rejection than ODN (OR 0.66, CI 0.5-0.87, P < .01). Analysis of the 0- to 5-yr recipient group showed no effect of ODN vs LDN on GF or rejection. For the contemporary era, there was no association between DGF and LDN in the 0- to 5-yr group (OR 1.12, CI 0.67-1.89, P = .67). Outcomes of kidney transplants in pediatric recipients following LDN have improved since its introduction and LDN should be the approach for live donor nephrectomy regardless of recipient age. The association between case volume and improved outcomes highlights future challenges in organ transplantation.

In vivo porcine training model of laparoscopic common bile duct repair with T-tube insertion under the situation of iatrogenic common bile duct injury

Purpose

We introduce a training porcine model for laparoscopic common bile duct (CBD) repair with T-tube insertion. The model could be the feasible training tool for a surgeon learning hepatobiliary surgery.

Methods

Totally laparoscopic CBD repair with T-tube insertion was performed on 9 pigs by 9 trainees naïve in hepatobiliary surgery. Similar to the situation of iatrogenic injury, CBD was transected by laparoscopic scissors at the middle part about 1 cm in length, and the transected CBD was repaired through end-to-end anastomosis with T-tube insertion. A secureness of anastomosis was confirmed by saline leakage test and all animals were sacrificed after the surgery.

Results

All novice surgeons completed operations successfully without complications. Total mean operative time was 85 ± 1.7 minutes and the mean time spent performing the CBD repair with T-tube insertion was 71 ± 3 minutes. There was no bile leakage after primary anastomosis in all animals.

Conclusion

This porcine training model for laparoscopic CBD repair with T-tube insertion could be a feasible and effective training tool for surgeons with little experience in laparoscopic hepatobiliary surgery.

Outcomes During a Transition Period from Open to Laparoscopic Pyloromyotomy

BACKGROUND

Previous studies suggest that laparosopic pyloromyotomy may have some benefits over an open approach. We examined our results during a transition period from open to laparoscopic pyloromyotomy to see whether these benefits are sustained during the learning curve.

METHODS

This is a retrospective case note review of all patients undergoing pyloromyotomy at a tertiary institution for a 5-year period (2010-2015). Data are presented as median (range). Statistical analysis was performed with Fisher's exact and Student's t-test.

RESULTS

A total of 185 pyloromyotomies were performed, with data available for 90 open and 60 laparoscopic procedures. Duration of surgery was 42 (16-102) minutes for open and 28 (14-97) minutes for laparoscopic procedures (P = .0001). Total paracetamol requirements were 23.5 (0-169.4) mg/kg for open and 13.9 (0-95.3) mg/kg for laparoscopic cases (P = .008). No postoperative analgesia was required for 23 open and 29 laparoscopic patients (P = .005). Complications in the open group included incomplete pyloromyotomy (n = 1) and wound infection (n = 4); complications in the laparoscopic group included incisional hernia (n = 1), omental port-site herniation (n = 2), and suspected perforation with conversion to open procedure, although no perforation was found (n = 1; P = 1.000).

CONCLUSION

Our results suggest that when the laparoscopic technique is first introduced, overall complication rates are not statistically higher, and operative times and analgesia requirements are significantly shorter, despite the learning curve.

Contribution of an educational video to surgical education in laparoscopic appendectomy

Objective

With recent widespread advances in laparoscopy, providing education on this subject has become a significant challenge. The aim of this study was to determine the degree of contribution made by surgeons to laparoscopic education through an educational video.

Material and Methods

A total of 40 volunteer general surgery residents and specialists participated in our study. Before watching the approximately six-minute educational video prepared for laparoscopic appendectomy, the participants were asked to fill out participant information forms and information measurement questionnaire forms. After the video, the participants were asked to fill out the information measurement questionnaire forms a second time; additionally, attitude evaluation forms and education evaluation questionnaire forms were presented to the participants for completion, and statistical analysis was performed. Furthermore, the total watching duration and the number of times the video was paused were recorded.

Results

A total of 40 surgeons participated in the study (75% residents and 25% specialists). When the results of the information determination questionnaire forms filled out by the resident and specialist groups before and after the video were compared, it was observed that the scores of both groups significantly increased after watching the video (p=0.001). A statistical significance was identified between the length of time the video was watched and the education evaluation form scores of the participants (p<0.01). It was observed that the longer the video was watched, the greater the increase in the education evaluation scores. The results of the attitude evaluation forms implied that the video could be produced more professionally.

Conclusion

Although education is an inevitable requirement of laparoscopic surgery, many teaching methods are available. Awareness-enhancing videos prepared on this topic can be efficient in providing laparoscopic education.

Minimally Invasive Hepatobiliary Surgery

Comparative studies and large-scale case series that confirm the advantages of laparoscopy in children with hepatobiliary diseases are scarce, and the use of laparoscopy remains a matter of debate. This article reviews the current literature on the role of laparoscopic and robotic surgery in pediatric patients with choledochal cyst, biliary atresia, gallbladder diseases, and hepatobiliary malignancies. Studies were identified through a search of the MEDLINE database. Laparoscopy may be beneficial for resection of choledochal cyst and cholecystectomy. However, more data are required before recommendations on the use of minimally invasive techniques for other hepatobiliary conditions can be published.

Clinical, Anatomical, and Pathological Grading Score to Predict Technical Difficulty in Laparoscopic Splenectomy for Non-traumatic Diseases

BACKGROUND

We aimed to develop a grading system based on preoperative parameters that would predict surgical difficulty and morbidity in elective laparoscopic splenectomy.

STUDY DESIGN

We retrospectively assessed morbidity in 439 patients who underwent laparoscopic splenectomy for benign and malignant disorders between 1993 and 2013. Medical and surgical records were reviewed and analyzed. We compared preoperative data concerning demographic, clinical, pathological, anatomical, laboratory, and radiological factors with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Univariate and multivariate analyses were performed to identify statistically significant variables. A logistic regression model was used to identify determinant variables and to compose a predictive score. External validation of the score was performed using an independent cohort of 353 patients.

RESULTS

Four preoperative parameters (age, male sex, type of pathology, and spleen size based on final spleen weight) were significantly related with operative time, operative bleeding, and conversion to open surgery. Using these results, we developed a classification system with three levels of difficulty: low (≤4 points), medium (4.5-5.5 points), and high (≥6 points), based on the four preoperative parameters. The correlation was highly significant (p = <0.001) according to Spearman's correlation. The area under the ROC curve was 0.671 (95 % CI 0.596-0.745). The external validation showed significant correlations with the present model.

CONCLUSIONS

The grading score described here is simple to calculate from the physical examination, laboratory tests, and US or CT images, and we believe it could be useful to preoperatively assess the technical complexity of laparoscopic splenectomy.

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator)

BACKGROUND

Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures.

METHODS

An ex vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session.

RESULTS

Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy.

CONCLUSIONS

We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees' comfort level in performing and assisting with myotomy and fundoplication.

3D vs. 2D imaging in laparoscopic surgery-an advantage? Results of standardised black box training in laparoscopic surgery

PURPOSE

3D imaging is an upcoming technology in laparoscopic surgery, and recent studies have shown that the modern 3D technique is superior in an experimental setting.

METHODS

All 14 members of the Asklepios Klinik Langen Department of Visceral and Thoracic Surgery, as well as two gynaecologists, were asked to undertake 2D vs. 3D laparoscopic black box skill training. The black box training was adapted to the "fundamentals of laparoscopic surgery" programme provided by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). First, the participants categorised themselves as beginner, advanced or expert in laparoscopic surgery. Then, they were randomised in terms of whether the black box training commenced with 2D or 3D vision. The exercises included peg transfer with the dominant hand and the non-dominant hand (with and without transfer between the graspers), needle capping and cutting a sutured knot. The time taken to complete these exercises was measured. After the training, each participant was asked to describe his/her personal impression of the imaging systems employed.

RESULTS

Overall, for the participants in all groups, the time required for all exercises showed a significant advantage for 3D imaging (3D vs. 2D; Wilcoxon matched pair test; mean 68.0 ± 94.9 s (3D) vs. 90.1 ± 69.4 s (2D); p = 0.002). Regarding the subgroups, the experts significantly improved their time in completing the exercises in 3D vs. 2D by a margin of 25.8 % (mean 30.8 ± 20.1 s (3D) vs. 41.5 ± 25.0 s (2D); p = 0.010). In the group of advanced surgeons, the results were similar, showing an improvement of 23.6 % for 3D, but without significance (mean 61.5 ± 41.1 s (3D) vs. 80.4 ± 72.8 s (2D); p = 0.123). The results for the beginner group also showed an improvement in the 3D exercises of 24.8 %; here, the result also showed a trend towards 3D but did not reach significance (mean 93.9 ± 90.7 s (3D) vs. 124.8 ± 118.72 (2D); p = 0.062).

CONCLUSION

In our opinion, 3D imaging could be an advantage in laparoscopic surgery, especially in the surgical education of upcoming surgical generations. To determine whether these ex vivo results can be transferred to the clinical situation, our group has initiated a randomised controlled study.

Learning curve after rapid introduction of laparoscopic appendectomy: are there any risks in surgical resident participation?

BACKGROUND

With the spread of the minimally invasive technique, laparoscopic appendectomy (LA) is performed with increasing frequency with excellent results. The method provides surgical residents with an excellent opportunity to learn basic laparoscopic skills and prepares them for more complex interventions.

METHODS

We evaluated the results of 600 laparoscopic appendectomies performed by 5 surgical residents (Group A) and 5 consultant surgeons (Group B) between 2006 and 2009. Comparing the two groups based on patient demographics, duration of surgery, operation time depending on the severity of inflammation, intraoperative blood loss, conversion rate, hospital stay in days, and postoperative complications. We also assessed the extent to which the minimum of 20 surgeries to be performed in the learning curve period as recommended by the EAES corresponds to our experience. SPPS 20 was used for the statistical analysis.

RESULTS

Six hundred laparoscopic appendectomies were performed in the study period (Group A: n = 319; Group B: n = 281). A significant difference was found between the two groups in duration of surgery during the learning curve period and when comparing the duration of LA surgeries in the learning curve period with the duration of later surgeries in both groups. The operation time in case of more severe inflammation also showed a significant difference when comparing with simple appendicitis operation time.

CONCLUSIONS

The rapid introduction of laparoscopy involves few risks, the surgery is also performed with sufficient safety by surgical residents, and it provides them with an excellent opportunity to learn the basic laparoscopy skills.

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre

BACKGROUND

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons.

OBJECTIVE

To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU).

STUDY DESIGN

The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg.

RESULTS

Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation.

DISCUSSION

There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre.

CONCLUSION

Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Surgical complications in kidney transplantation: no evidence for a learning curve

OBJECTIVE

To evaluate whether surgical complications after kidney transplantation correlate with surgeon's experience and whether individual surgeons' complication rates improve during their learning process.

STUDY DESIGN

Retrospective analysis: A generalized linear mixed-effects model was used to identify risk factors for surgical complications. Plots of cumulative sums of complications were used to evaluate the individual surgeons' performance.

SETTING

Single-center experience of a teaching hospital in Switzerland.

PARTICIPANTS

Consecutive kidney transplant recipients operated from 1962 until 2003.

RESULTS

A total of 1496 kidney transplants were analyzed; 73% were from deceased donors and 27% from living donors. At least 1 surgical complication occurred in 352 patients (24%). Male gender (odds ratio [OR] = 1.35, 95% CI: 1.04-1.74), donor's age (OR = 1.14, 95% CI: 1.06-1.24 per decade increment), and third or fourth vs. first or second transplant in a recipient (OR = 2.90, 95% CI: 1.02-8.24) were significantly associated with surgical complications. The surgeon's transplant experience was not found to be associated with surgical complications. Even surgeons with an experience of less than 10 kidney transplants did not have higher complication rates, 30-day mortality, or 1-year graft survival. Individual surgeons' complication rates analyzed by cumulative sum plots did not improve with increasing experience.

CONCLUSIONS

We present the largest single-center study on surgical complications after kidney transplantation, with unique data on the surgeon's experience for every single procedure. We found no evidence for a learning curve during training for kidney transplantation. We conclude that carefully selected experienced general and vascular surgeons can achieve good results in kidney transplantation after a relatively short training period.

Is current surgical training efficient? A national survey

OBJECTIVES

Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.

DESIGN AND PARTICIPANTS

A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.

RESULTS

The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.

CONCLUSIONS

Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

Robotic sacrocolpopexy performance and cumulative summation analysis

OBJECTIVES

This study aimed to apply Cumulative Summation (CUSUM) analysis as a tool to monitor robotic sacrocolpopexy (RSCP) proficiency over time.

METHODS

A retrospective analysis of all women who underwent RSCP between September of 2008 and December of 2011 at the University of North Carolina at Chapel Hill. The performance for 2 attending surgeons was analyzed sequentially over time. Intraoperative complications such as genitourinary or gastrointestinal tract injury, conversion to laparotomy, pulmonary embolus, hemorrhage, and blood transfusion, were identified by International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. A successful outcome was defined as no intraoperative complications. The target value of success was set at less than 10% complications. CUSUM analysis was then sequentially applied to all RSCP cases for 2 attending surgeons.

RESULTS

Over 27 months, 169 RSCPs were performed. The first surgeon performed 107 RSCPs and the second surgeon performed 62 RSCPs with 8 (7.4%) and 3 (4.9%) intraoperative complications, respectively. Total complications included 7 (4.1%) cystotomies, 2 (1.2%) vaginal lacerations, 1 (0.6%) blood transfusion, and 1 (0.6%) bowel perforation. A CUSUM graph was created for each surgeon.

CONCLUSIONS

CUSUM analysis was successfully applied to monitor RSCP proficiency. Such testing of individual successive procedural outcomes with CUSUM may offer an objective tool to aid in physician self-assessment.

Student attainment of proficiency in a clinical skill: the assessment of individual learning curves

The aims of this study were to determine if the learning curve cumulative summation test (LC-CUSUM) can differentiate proficiency in placing intravenous catheters by novice learners, and identify the cause of failure when it occurred. In a prospective, observational study design 6 undergraduate students with no previous experience of placing intravenous catheters received standardized training by a board certified veterinary anesthesiologist in intravenous catheter placement technique. Immediately following training, each student attempted 60 intravenous catheterizations in a dog mannequin thoracic limb model. Results were scored as a success or failure based upon completion of four specific criteria, and where catheter placement failure occurred, the cause was recorded according to pre-defined criteria. Initial acceptable and unacceptable failure rates were set by the study team and the LC-CUSUM was used to generate a learning curve for each student. Using 10% and 25% acceptable and unacceptable failure rates, 3 out of 6 students attained proficiency, requiring between 26 to 48 attempts. Applying 25% and 50% acceptable and unacceptable failure rates, 5 of 6 students obtained proficiency, requiring between 18 and 55 attempts. Wide inter-individual variability was observed and the majority of failed catheterisation attempts were limited to two of the four pre-defined criteria. These data indicate that the LC-CUSUM can be used to generate individual learning curves, inter-individual variability in catheter placement ability is wide, and that specific steps in catheter placement are responsible for the majority of failures. These findings may have profound implications for how we teach and assess technical skills.

Survival after hepatic resection: impact of surgeon training on long-term outcome

BACKGROUND

Mortality for liver resection has remarkably improved owing to multiple factors. We sought to determine the impact of the various types of fellowship training on patient survival after liver resection.

METHODS

Patients who underwent hepatic resection between 1995 and 2004 in either the Calgary or Capital health regions (Edmonton) of Alberta, Canada, were identified using ICD-9 and -10 codes. Primary outcomes included in-hospital mortality and patient survival according to surgeon volume and training type (surgical oncology v. hepatobiliary v. others).

RESULTS

A total of 1033 patients underwent hepatic resection. Surgeon volume was not predictive of either in-hospital mortality (adjusted odds ratio 0.63, 95% confidence interval [CI] 0.32-1.20) or patient survival (unadjusted hazard ratio 1.11, 95% CI 0.82-1.51). Nonsignificance was also demonstrated for a surgeon's type of fellowship training.

CONCLUSION

The various modes of fellowship training do not appear to influence inhospital mortality or patient survival after hepatic resection.

Minimally invasive splenectomy: an update and review

Laparoscopic splenectomy (LS) has become an established standard of care in the management of surgical diseases of the spleen. The present article is an update and review of current procedures and controversies regarding minimally invasive splenectomy. We review the indications and contraindications for LS as well as preoperative considerations. An individual assessment of the procedures and outcomes of multiport laparoscopic splenectomy, hand-assisted laparoscopic splenectomy, robotic splenectomy, natural orifice transluminal endoscopic splenectomy and single-port splenectomy is included. Furthermore, this review examines postoperative considerations after LS, including the postoperative course of uncomplicated patients, postoperative portal vein thrombosis, infections and malignancy.

Technical competence in surgeons

In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.

The relationship between volume and outcome after bariatric surgery: a nationwide study in Taiwan

BACKGROUND

This study purposed to explore the impact of hospital volume and surgeon volume on hospital resource utilization after bariatric surgery and to identify the predictors of length of stay (LOS) and hospital treatment cost in a nationwide population in Taiwan.

METHODS

This population-based cohort study retrospectively analyzed 2,674 bariatric surgery procedures performed from 1997 to 2008. Hospitals were classified as low- and high-volume hospitals if their annual number of bariatric surgeries were <35 and ≥ 35, respectively. Surgeons were classified as low- and high-volume surgeons if their annual number of bariatric surgeries were <15 and ≥ 15, respectively. Hierarchical linear regression models were used to predict LOS and hospital treatment cost.

RESULTS

The mean LOS was 7.67 days and the LOS for high-volume hospitals/surgeons was, on average, 28%/31% shorter than that for low-volume hospitals/surgeons. The mean hospital treatment cost was US$2,344.08, and the average hospital costs for high-volume hospitals/surgeons were 10%/13% lower than those for low-volume hospitals/surgeons. Advanced age, male gender, high Charlson co-morbidity index, and current treatment in a low-volume hospital, by a low-volume surgeon, and via open gastric bypass were significantly associated with long LOS and high hospital treatment cost (P < 0.001).

CONCLUSIONS

The data suggest that annual surgical volume is the key factor in hospital resource utilization. The results improve the understanding of medical resource allocation for this surgical procedure and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy

BACKGROUND

Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy.

METHODS

From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients' demographics, perioperative data, clinical outcome, and hematological changes were analyzed.

RESULTS

Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period.

CONCLUSIONS

Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.

Minimally Invasive Training During Surgical Residency

The field of postgraduate minimally invasive surgery training has undergone substantial growth and change. A survey was sent to all program directors in surgery. Minimally invasive training patterns, facilities, their views, and performance of residents were examined. Ninety-five directors (38%) responded to the questionnaire. Of these, 51 per cent (n = 48) had a program size of three to four residents and 33 per cent (n = 31) had a program size of five to six residents. In 3 per cent of programs (n = 3), residents could not achieve the minimum Accreditation Council for Graduate Medical Education required numbers for advanced laparoscopic cases. Only 47 per cent of programs (n = 45) had dedicated rotations in minimally invasive surgery, ranging from 2 to 11 months. Up to 10 per cent (n = 9) of program directors felt that the current training in minimally invasive surgery was insufficient. Fifty-five per cent (n = 52) felt that laparoscopic adhesiolysis was an advanced laparoscopic procedure, and 33 per cent (n = 31) felt that there should be a separate minimum requirement for each of the commonly performed basic and advanced laparoscopic cases by Accreditation Council for Graduate Medical Education. Fifty-six per cent (n = 53) of programs were performing robotic surgery. Minimally invasive surgery training for surgical residents needs to increase opportunities so that they are able to perform laparoscopic procedures with confidence. There should be specific number requirements in each category of individual basic and advanced laparoscopic procedures.

Value of an objective assessment tool in the operating room

BACKGROUND

Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use.

METHODS

Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience.

RESULTS

Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors.

CONCLUSION

Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.

Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model

OBJECTIVE

We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures.

STUDY DESIGN

A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted.

RESULTS

The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor.

CONCLUSION

The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.

Laparoscopic versus transverse Incision right colectomy for colon carcinoma

AIM

We investigated whether laparoscopic right colectomy has short-term and ⁄ or oncological advantages compared with transverse incision right colectomy.

METHOD

Patients who underwent an elective laparoscopic right colectomy or an open right colectomy through a transverse incision at the VU University Medical Center or Zaans Medical Center from 2005 to 2009 were prospectively followed.

RESULTS

Patient groups were comparable in terms of gender, body mass index and American Society of Anesthesiology classification. Patients in the transverse incision group were older (68 years vs 75 years, P = 0.07) and blood loss was greater during this procedure (60 ml vs 130 ml, P = 0.001), which cost less than the laparoscopic procedure (€6.033 vs €7.221, P = 0.03). Hospital stay for the laparoscopic group was shorter (8 days vs 9 days, P = 0.04), but laparoscopic procedures took longer (155 min vs 77 min, P < 0.001) and 8% of patients in the laparoscopic group were converted to a median laparotomy. Postoperative complications were comparable for both groups (28% vs 32%, P = 0.74), and in both groups a radical resection rate of 96% (P = 0.94) was achieved. At a median follow up of 20 months the incidence of incisional hernia was similar in both groups and no patient required additional surgery as a result. Overall survival at 60 months was 70% for the laparoscopic group and 67% for the transverse incision group (P = 0.84).

CONCLUSION

There a re few clinically relevant differences between a laparoscopic right colectomy and a transverse incision right colectomy. Transverse incision right colectomy is cheaper. The study may be the first to compare these two techniques, but it is a nonrandomized trial and therefore has its limitations.

Toward effective pediatric minimally invasive surgical simulation

BACKGROUND/PURPOSE

Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons.

METHODS

We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency.

RESULTS

For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups.

CONCLUSION

Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool.

Does laparoscopy lower the threshold for the surgical treatment of gastroesophageal reflux disease in children?

OBJECTIVE

To assess whether laparoscopic surgery lowers the threshold for surgical intervention, we examined whether the introduction of the laparoscopic technique at our institution in 1997 has resulted in an increase in antireflux surgery in children at our clinic.

PATIENTS AND METHODS

The number of annual fundoplications between 1997 and 2008 at a single institution was assessed in children younger than 18 years. The number of fundoplications was compared with the number of pyloromyotomies and appendicectomies per year in the same period of time to prove or exclude a general increase in the referral of children.

RESULTS

Since 1997, the proportion of laparoscopic fundoplications increased from 60% in 1997 to 100% in 2008. During this period, 109 laparoscopic fundoplications were performed: 31 in the period from 1997 to 2002 and 78 from 2003 to 2008. Regression analysis shows a significant increase in the number of performed fundoplications (slope: 1.03 ± 0.28, P = 0.0043), whereas both the number of pyloromyotomies and appendicectomies remained stable (slopes: -0.14 ± 0.40, P = 0.73, and -0.75 ± 0.47, P = 0.14, respectively).

CONCLUSIONS

Since the introduction of minimally invasive surgery at our tertiary referral center in 1997, the number of patients referred for an antireflux operation has increased. This cannot be explained by an increase of referrals from outside the region or a change in the indication for surgery. We conclude that laparoscopy lowers the threshold for the surgical treatment of gastroesophageal reflux disease in children.

Evaluation of laparoscopic management of gynecologic emergencies by residents

OBJECTIVE

To evaluate the feasibility of laparoscopic management of women with gynecologic emergencies by the residents and the chief resident in an organized resident training program.

METHODS

A retrospective study of patients with gynecologic emergencies who underwent laparoscopic surgery between January 1, 1999, and May 31, 2006 was done.

RESULTS

For the 369 patients included, the mean operative time of 74±31.35 minutes was significantly increased by advanced patient age (P<0.001), pelvic inflammatory disease with or without tubo-ovarian abscess (PID±TOA) (P<0.050), the first semester of chief residency (P<0.050), and conversion to laparotomy (P<0.001). Mean length of hospital stay was 40±24 hours. Factors such as advanced patient age (P<0.001), prolonged length of surgery (P<0.001), PID±TOA (P<0.001), first semester of chief residency (P<0.050), conversion to laparotomy (P<0.001), and blood transfusion (P<0.050) significantly increased the length of hospital stay. The conversion rate to laparotomy was 4.6% (n=17), and it was significantly associated with advanced women age (OR 1.11; 95% CI, 1.05-1.17, P<0.001) and PID±TOA (OR 6.04; 95%CI, 2.17-16.62, P<0.001). Postoperative complications were recorded in 3 (0.81%) patients.

CONCLUSION

Laparoscopic management of gynecologic emergencies by senior residents and a chief resident within an organized resident training program is feasible. These results reinforce the relevance of a well-structured residency endoscopic training program.