The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club

Bile Duct Injuries During Urgent Cholecystectomy at a Safety Net Teaching Hospital: Attending Experience and Time of Day May Matter

Background: Bile duct injury (BDI) is one of the most severe complications during cholecystectomy. Early identification of risk factors for BDI may permit risk reduction strategies and inform patient consent.Objective: This study aimed to define patient, provider, and systemic factors associated with BDI; BDI incidence; and short-term outcomes of BDI after urgent cholecystectomy.Methods: Patients who underwent urgent cholecystectomy for acute cholecystitis were retrospectively screened (2020-2022). All patients who sustained BDI were included without exclusions. Demographics, clinical data, and outcomes were collected and compared with descriptive statistics.Results: During the study period, BDI occurred in 4 (0.5%) of 728 patients who underwent urgent cholecystectomy for acute cholecystitis. Most BDI cases (75%) took place overnight or during the weekend. The attending surgeon was almost exclusively (75%) in their first year of practice. BDI was recognized during index operation in 2 cases (50%). Hepatobiliary surgery performed the bile duct repair in all 4 cases. Two complications occurred (50%). All patients were followed by hepatobiliary surgery in the outpatient setting and returned to their baseline level of function within 2 months of hospital discharge.Conclusion: Most BDI occurred in procedures attended by first-year faculty during after hours cholecystectomies, suggesting a role for increased proctorship in early career attendings in addition to in-hours cholecystectomy for acute cholecystitis. The timely return to baseline function experienced by these patients emphasizes the favorable outcomes associated with early recognition of BDI and involvement of hepatobiliary surgery. Further examination with multicenter evaluation would be beneficial to validate these study findings.

Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis

BACKGROUND

With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied.

METHODS

We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization.

RESULTS

Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001).

CONCLUSIONS

The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

Decoding surgical skill: an objective and efficient algorithm for surgical skill classification based on surgical gesture features -experimental studies

BACKGROUND

Various surgical skills lead to differences in patient outcomes and identifying poorly skilled surgeons with constructive feedback contributes to surgical quality improvement. The aim of the study was to develop an algorithm for evaluating surgical skills in laparoscopic cholecystectomy based on the features of elementary functional surgical gestures (Surgestures).

MATERIALS AND METHODS

Seventy-five laparoscopic cholecystectomy videos were collected from 33 surgeons in five hospitals. The phase of mobilization hepatocystic triangle and gallbladder dissection from the liver bed of each video were annotated with 14 Surgestures. The videos were grouped into competent and incompetent based on the quantiles of modified global operative assessment of laparoscopic skills (mGOALS). Surgeon-related information, clinical data, and intraoperative events were analyzed. Sixty-three Surgesture features were extracted to develop the surgical skill classification algorithm. The area under the receiver operating characteristic curve of the classification and the top features were evaluated.

RESULTS

Correlation analysis revealed that most perioperative factors had no significant correlation with mGOALS scores. The incompetent group has a higher probability of cholecystic vascular injury compared to the competent group (30.8 vs 6.1%, P =0.004). The competent group demonstrated fewer inefficient Surgestures, lower shift frequency, and a larger dissection-exposure ratio of Surgestures during the procedure. The area under the receiver operating characteristic curve of the classification algorithm achieved 0.866. Different Surgesture features contributed variably to overall performance and specific skill items.

CONCLUSION

The computer algorithm accurately classified surgeons with different skill levels using objective Surgesture features, adding insight into designing automatic laparoscopic surgical skill assessment tools with technical feedback.

There is a need for a paradigm shift in laparoscopic surgical training: results of a nationwide survey among teaching hospitals in Switzerland

BACKGROUND

Surgical training curricula have changed little over the past decades. Current advances in surgical techniques, especially in minimally invasive surgery, as well as the rapidly changing socioeconomic environment pose a major challenge for the training of young surgeons. The aim of this survey was to provide a representative overview of the surgical training landscape in Switzerland focusing on laparoscopic surgical training: How do department chairs of teaching hospitals deal with the above challenges, and what should a future training curriculum look like?

METHODS

This is a prospective, questionnaire-based, cross-sectional study among the heads of departments of all certified surgical teaching hospitals in Switzerland.

RESULTS

The overall response rate was 56% (48/86) and 86% (19/22) for tertiary centers. Two-thirds of the centers (32) organize themselves in training networks. Laparoscopic training courses are offered in 25 (52%) hospitals, mainly in tertiary centers. Self-training opportunities exist in 40 (83%) hospitals. In addition to commercial (27) and self-built (7) box trainers, high-fidelity trainers are available in 16 (33%) hospitals. A mandatory training curriculum exists in 7 (15%) facilities, and a training assessment is performed in 15 (31%) institutions. Thirty-two (65%) heads of departments indicated that residents have sufficient practical exposure in the operating room, but the ability to work independently with obtaining the specialist title is seen critically (71%). They state that the surgical catalog does not adequately reflect the manual skills of the resident (64%). The desire is for training to be restructured from a numbers-based to a performance-based curriculum (53%) and for tools to assess residents' manual skills (56%) to be introduced.

CONCLUSIONS

Department chairs stated that the existing curriculum in Switzerland does not meet the requirements of a modern training curriculum. This study highlights the need to create an improved, competency-based curriculum that ensures the training of a new generation of surgeons, taking into account the growing evidence of the effectiveness of state-of-the-art training modalities such as simulation or proficiency-based training.

A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety

BACKGROUND

The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice.

METHODS

A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes.

RESULTS

Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability.

CONCLUSIONS

A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees

AIMS

The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST.

METHODS

This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction.

RESULTS

Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences.

CONCLUSIONS

These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa

BACKGROUND

Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries.

METHODS

Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored.

RESULTS

One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level.

CONCLUSIONS

Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.

Early Evaluation of a New French Surgery Course in the Best Practice of Dealing With Major Incidents and Mass Casualty Events

OBJECTIVE

The main objective of this study is to evaluate the impact of a nationwide 5-month course aimed to prepare surgeons for Major Incidents through the acquisition of key knowledge and competencies. Learners' satisfaction was also measured as a secondary objective.

DESIGN

This course was evaluated thanks to various teaching efficacy metrics, mainly based on Kirkpatrick's hierarchy in medical education. Gain in knowledge of participants was evaluated by multiple-choice tests. Self-reported confidence was measured with 2 detailed pre and post training questionnaires.

SETTING

Creation in 2020 of a nationwide, optional and comprehensive Surgical Training in War and Disaster Situation as part of the French surgery residency program. In 2021, data was gathered regarding the impact of the course on participants' knowledge and competencies.

PARTICIPANTS

The study included 26 students in the 2021 cohort (13 residents and 13 practitioners).

RESULTS

Mean scores were significantly higher in the post-test compared to the pre-test, showing significant increase in participants' knowledge during the course: 73,3% vs. 47,3% respectively (p ≤ 0.001). Average learners' confidence scores to perform technical procedures showed at least a +1-point increase on the Likert scale for 65% of items tested (p ≤ 0.001). 89% of items showed at least a +1-point increase on the Likert scale when it came to average learners' confidence score on dealing with complicated situations (p ≤ 0.001). Our post-training satisfaction survey showed that 92% of all participants have noticed the impact of the course on their daily practice.

CONCLUSION

Our study shows that the third level of Kirkpatrick's hierarchy in medical education was reached. This course therefore appears to be meeting the objectives set by the Ministry of Health. Being only 2 years old, it is on the road to gathering momentum and further development.

Laparoscopic simulator performance and learning curves under different optical angles

BACKGROUND

Deviated optical angles create visuospatial and psychomotor challenges during laparoscopic procedures, resulting in delayed operative time and possibly adverse events. If it is possible to train the skills needed to work under these deviated optical angles, this could benefit procedure time and patient safety. This study investigates the influence of the optical angle on development of basic laparoscopic surgical skills.

METHODS

A total of 58 medical students performed a four-session laparoscopic training course on a Virtual Reality Simulator. During each session, they performed an identical task under optical angles of 0°, 45° and - 45°. Performance parameters of task duration and damage were compared between the optical angles to investigate the effect of optical angle on performance development. The 4th session performance was compared to the 2nd session performance for each angle to determine improvement.

RESULTS

Participants performed the task significantly faster under the 0° optical angle compared to the plus and minus 45° optical angles during the last three sessions (z between - 2.95 and - 2.09, p < .05). Participants improved significantly and similarly for task duration during the training course under all optical angles. At the end of the training course however significant performance differences between the zero and plus/minus 45 optical angles remained. Performance for damage did not improve and was not affected by optical angle throughout the course.

CONCLUSION

Dedicated virtual reality training improves laparoscopic basic skills performance under deviated optical angles as it leads to shorter task duration, however a lasting performance impairment compared to the 0° optical angle remained. Training for performing under deviating optical angles can potentially shorter the learning curve in the operating room.

Educational Scoring System in Laparoscopic Cholecystectomy: Is It the Right Time to Standardize?

Background and Objectives: Laparoscopic cholecystectomy (LC) is one of the most performed surgeries worldwide. Procedure difficulty and patient outcomes depend on several factors which are not considered in the current literature, including the learning curve, generating confusing and subjective results. This study aims to create a scoring system to calculate the learning curve of LC based on hepatobiliopancreatic (HPB) experts' opinions during an educational course. Materials and Methods: A questionnaire was submitted to the panel of experts attending the HPB course at Research Institute against Digestive Cancer-IRCAD (Strasbourg, France) from 27-29 October 2022. Experts scored the proposed variables according to their degree of importance in the learning curve using a Likert scale from 1 (not useful) to 5 (very useful). Variables were included in the composite scoring system only if more than 75% of experts ranked its relevance in the learning curve assessment ≥4. A positive or negative value was assigned to each variable based on its effect on the learning curve. Results: Fifteen experts from six different countries attended the IRCAD HPB course and filled out the questionnaire. Ten variables were finally included in the learning curve scoring system (i.e., patient body weight/BMI, patient previous open surgery, emergency setting, increased inflammatory levels, presence of anatomical bile duct variation(s), and appropriate critical view of safety (CVS) identification), which were all assigned positive values. Minor or major intraoperative injuries to the biliary tract, development of postoperative complications related to biliary injuries, and mortality were assigned negative values. Conclusions: This is the first scoring system on the learning curve of LC based on variables selected through the experts' opinions. Although the score needs to be validated through future studies, it could be a useful tool to assess its efficacy within educational programs and surgical courses.

Magnetic resonance cholangiopancreatography enhanced by virtual reality as a novel tool to improve the understanding of biliary anatomy and the teaching of surgical trainees

Objective

The novel picture archiving and communication system (PACS), compatible with virtual reality (VR) software, displays cross-sectional images in VR. VR magnetic resonance cholangiopancreatography (MRCP) was tested to improve the anatomical understanding and intraoperative performance of minimally invasive cholecystectomy (CHE) in surgical trainees.

Design

We used an immersive VR environment to display volumetric MRCP data (Specto VRTM). First, we evaluated the tolerability and comprehensibility of anatomy with a validated simulator sickness questionnaire (SSQ) and examined anatomical landmarks. Second, we compared conventional MRCP and VR MRCP by matching three-dimensional (3D) printed models and identifying and measuring common bile duct stones (CBDS) using VR MRCP. Third, surgical trainees prepared for CHE with either conventional MRCP or VR MRCP, and we measured perioperative parameters and surgical performance (validated GOALS score).

Setting

The study was conducted out at Clarunis, University Center for Gastrointestinal and Liver Disease, Basel, Switzerland.

Participants

For the first and second study step, doctors from all specialties and years of experience could participate. In the third study step, exclusively surgical trainees were included. Of 74 participating clinicians, 34, 27, and 13 contributed data to the first, second, and third study phases, respectively.

Results

All participants determined the relevant biliary structures with VR MRCP. The median SSQ score was 0.75 (IQR: 0, 3.5), indicating good tolerability. Participants selected the corresponding 3D printed model faster and more reliably when previously studying VR MRCP compared to conventional MRCP: We obtained a median of 90 s (IQR: 55, 150) and 72.7% correct answers with VR MRCP versus 150 s (IQR: 100, 208) and 49.6% correct answers with conventional MRCP, respectively (p &lt; 0.001). CBDS was correctly identified in 90.5% of VR MRCP cases. The median GOALS score was higher after preparation with VR MRCP than with conventional MRCP for CHE: 16 (IQR: 13, 22) and 11 (IQR: 11, 18), respectively (p = 0.27).

Conclusions

VR MRCP allows for a faster, more accurate understanding of displayed anatomy than conventional MRCP and potentially leads to improved surgical performance in CHE in surgical trainees.

On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies: A 7-year audit

BACKGROUND

Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy.

METHODS

This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected.

RESULTS

The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality.

CONCLUSIONS

Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.

Robotic Surgery: Rediscovering Human Anatomy

Since its advent, robotic surgery has redefined the operating room experience. It directly addressed and resolved many of the shortcomings of laparoscopic methods while maintaining a minimally invasive approach that brought benefits in cosmesis and healing for patients but also benefits in ergonomics and precision for surgeons. This new platform has brought with it changes in surgical training and education, principally through the utilization of virtual reality. Accurate depictions of human anatomy seen through augmented reality allow the surgeon-in-training to learn, practice and perfect their skills before they operate on their first patient. However, the anatomical knowledge required for minimally invasive surgery (MIS) is distinct from current methods of dissection and prosection that inherently cater towards open surgery with large cuts and unobstructed field. It is integral that robotic surgeons are also equipped with accurate anatomical information, heralding a new era in which anatomists can work alongside those developing virtual reality technology to create anatomical training curricula for MIS. As the field of surgery and medicine in general moves to include more and more technology, it is only fitting that the building blocks of medical education follow suit and rediscover human anatomy in a modern context.

Three-Dimensional Endoscopic Endonasal Surgery: A Systematic Review

OBJECTIVES

To compare participant performance and preference in the use of three-dimensional (3D) endoscopy compared to traditional two-dimensional (2D) endoscopy.

METHODS

PubMed, Embase, Medline, ClinicalKey, BMJ Case Reports, and the Cochrane library were systematically searched for English-language articles published between 2005 and 2020. Studies reporting comparisons of outcomes between 3D and 2D endoscopes were identified. Data relating to performance-related outcomes, as well as the participants' preferred endoscope were extracted, and pooled using meta-analysis models.

RESULTS

Ten studies were included in the qualitative synthesis. Six studies reported results of participants completing simulated tasks with endoscopes, while four reported full procedures. Peg transfer tasks (n = 4 cohorts) were found to be completed significantly faster with the 3D versus 2D endoscope (pooled mean difference 6.8 seconds, 95% confidence interval [CI]: 2.3-11.3), while no significant difference in times taken was observed for touch tasks (n = 4; pooled mean difference 3.7 seconds, 95% CI: -1.9 to 9.2). The secondary outcome of participant preference was reported by five studies, in which a significant preference for the 3D endoscope was observed (P = .010), with a pooled total of 72% (95% CI: 59-83) of participants preferring this to the 2D endoscope.

CONCLUSIONS

There is a growing body of evidence in support of 3D visualization in endoscopy. We have demonstrated 3D endoscopy to be associated with a significantly shorter time to performing simulated, reproducible and controlled tasks, and to be the preference of participants. This study provides grounds for further evaluation of the technology, and the potential for a greater widespread use. Laryngoscope, 2021.

Laparoscopic skills training: the effects of viewing mode (2D vs. 3D) on skill acquisition and transfer

BACKGROUND

Three-dimensional (3D) visual displays have been suggested to aid laparoscopic skills training by providing the depth cues not present in traditional two-dimensional (2D) displays. However, few studies have robustly investigated the impact of viewing mode (2D vs. 3D) on learning outcomes.

PURPOSE

To examine how viewing mode (2D vs. 3D) impacts the acquisition and transferability of basic laparoscopic skills by comparing performance between transfer and control groups on a complete proficiency-based training program.

METHOD

A counterbalanced between-subjects design was employed. Each participant was randomly allocated to one of four groups, comprising two transfer groups (trained in one viewing mode and tested in the alternate mode: the 2D → 3D and 3D → 2D groups) and two control groups (trained and tested in one viewing mode: the 2D → 2D and 3D → 3D groups). Participants completed proficiency-based training in six laparoscopic training tasks. Testing included two further repetitions of all tasks under test conditions. Objective performance measures included the total number of repetitions to reach proficiency, and total performance scores (i.e. time + error penalties across all repetitions) in training and testing.

RESULTS

The groups trained in 3D demonstrated superior training performance (i.e. less time + errors) and took fewer repetitions to reach proficiency than the groups trained in 2D. The groups tested in 3D also demonstrated superior test performance compared to those tested in 2D. However, training mode did not yield significant test differences between the groups tested in 2D (i.e. 2D → 2D vs. 3D → 2D), or between the groups tested in 3D (i.e. 3D → 3D vs. 2D → 3D).

CONCLUSION

Novices demonstrate superior performance in laparoscopic skills training using a 3D viewing mode compared to 2D. However, this does not necessarily translate to superior performance in subsequent testing or enhanced learning overall. Rather, test performance appears to be dictated by the viewing mode used during testing, not that of prior training.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.

METHODS

Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.

RESULTS

Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.

CONCLUSIONS

The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review

Background

Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear.

Methods

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle–Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles.

Results

Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut‐off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies.

Conclusions

The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy.

Assessment of technical skills based on learning curve analyses in laparoscopic surgery training

BACKGROUND

Objective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training.

METHODS

Laparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity.

RESULTS

In total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9-3.8) to 1.8 Newton (interquartile range 1.2-2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2-9,025.9) to 3,545.3 mm (interquartile range 2,842.9-4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8-219.0) to 60.7 seconds (interquartile range 46.0-79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation).

CONCLUSION

Force-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise.

Role of Digital Resources in Minimally Invasive Colorectal Surgery Training

Laparoscopic techniques have become the standard for many benign and malignant colorectal pathologies. Recently, the application of robotic-assisted technologies has been, and continues to be, explored. These new technologies require different skill sets and bring novel training challenges, and today's trainees must demonstrate competence in more techniques than ever. Compounding this is the reducing time spent operating in current training programs due to caps on working hours and service pressures. The need for adjunctive training strategies outside the operating room has prompted development of multimedia and digital resources to build the cognitive skills crucial in both nontechnical and technical aspects of surgery. Many are based on principles of cognitive task analysis, breaking down operations, and key decisions into nodal points to be mentally rehearsed. Resources built on this technique have shown improvements in both operative and nonoperative skills, suggesting these resources can advance trainees along the learning curve in minimally invasive surgical techniques. More work to fully elucidate the clinical benefits of such resources is required before their role as a substitute for lost operative training hours can be established. Despite this, alongside other developing technologies such as simulation, they are a promising addition to the armamentarium of the modern-day colorectal trainee.

Training on Minimally Invasive Colorectal Surgery during Surgical Residency: Integrating Surgical Education and Advanced Techniques

Surgery is an ever-evolving discipline and continually incorporates new technologies that have improved the ability of the operating room surgeon to perform. The next generation of minimally invasive surgery includes laparoscopic and robotic-assisted procedures. Graduating residents may be expected to have the skills to perform common colorectal procedures using these technologies, and residency programs are developing curriculums to teach these skills. Minimally invasive techniques are challenging and learning only by observation and practice alone is difficult. This requires dedicated training and mentoring. New simulation methods have been conceived specifically for minimally invasive procedures, and these embrace a combination of virtual reality simulators and box trainers, with animal and human tissue, as well as synthetic materials. The aim of this review is to provide an overview of training in minimally invasive colorectal surgery with a focus on different types of simulators that build the basis to develop and include a multistep training approach in a structured training curriculum for minimally invasive colorectal procedures.

Validation of a high-fidelity training model for fetoscopic spina bifida surgery

Open fetal surgery for spina bifida (SB) is safe and effective yet invasive. The growing interest in fetoscopic SB repair (fSB-repair) prompts the need for appropriate training. We aimed to develop and validate a high-fidelity training model for fSB-repair. fSB-repair was simulated in the abdominal cavity and on the stomach of adult rabbits. Laparoscopic fetal surgeons served either as novices (n = 2) or experts (n = 3) based on their experience. Technical performance was evaluated using competency Cumulative Sum (CUSUM) analysis and the group splitting method. Main outcome measure for CUSUM competency was a composite binary outcome for surgical success, i.e. watertight repair, operation time ≤ 180 min and Objective-Structured-Assessment-of-Technical-Skills (OSATS) score ≥ 18/25. Construct validity was first confirmed since competency levels of novices and experts during their six first cases using both methods were significantly different. Criterion validity was also established as 33 consecutive procedures were needed for novices to reach competency using learning curve CUSUM, which is a number comparable to that of clinical fSB-repair. Finally, we surveyed expert fetal surgeons worldwide to assess face and content validity. Respondents (26/49; 53%) confirmed it with ≥ 71% of scores for overall realism ≥ 4/7 and usefulness ≥ 3/5. We propose to use our high-fidelity model to determine and shorten the learning curve of laparoscopic fetal surgeons and retain operative skills.

Augmented Reality, Mixed Reality, and Hybrid Approach in Healthcare Simulation: A Systematic Review

Simulation-based medical training is considered an effective tool to acquire/refine technical skills, mitigating the ethical issues of Halsted’s model. This review aims at evaluating the literature on medical simulation techniques based on augmented reality (AR), mixed reality (MR), and hybrid approaches. The research identified 23 articles that meet the inclusion criteria: 43% combine two approaches (MR and hybrid), 22% combine all three, 26% employ only the hybrid approach, and 9% apply only the MR approach. Among the studies reviewed, 22% use commercial simulators, whereas 78% describe custom-made simulators. Each simulator is classified according to its target clinical application: training of surgical tasks (e.g., specific tasks for training in neurosurgery, abdominal surgery, orthopedic surgery, dental surgery, otorhinolaryngological surgery, or also generic tasks such as palpation) and education in medicine (e.g., anatomy learning). Additionally, the review assesses the complexity, reusability, and realism of the physical replicas, as well as the portability of the simulators. Finally, we describe whether and how the simulators have been validated. The review highlights that most of the studies do not have a significant sample size and that they include only a feasibility assessment and preliminary validation; thus, further research is needed to validate existing simulators and to verify whether improvements in performance on a simulated scenario translate into improved performance on real patients.

Learning curve assessment for total ankle replacement using the transfibular approach

BACKGROUND

Total ankle arthroplasty is an increasingly effective option for the treatment of end-stage arthritis. One recent innovation utilizes a transfibular, lateral approach. Like any new system, there is likely a learning curve associated with its use. We analyzed a series of patients who received a total ankle arthroplasty via a transfibular approach to state if it is possible to identify and to evaluate effects of a learning curve in the use of this novel total ankle replacement system.

METHODS

76 consecutive patients meeting inclusion and exclusion criteria were retrospectively analyzed. All patients had a minimum of 24 months of follow-up. Intraoperative parameters, preoperative and postoperative subjective outcome scores, radiographic parameters, and complications were recorded and evaluated.

RESULTS

There were significant learning curve effects on various surgical and postoperative parameters. Surgical time decreased with the curve stabilizing after the 16th patient. With regard to patient outcomes, a learning curve was identified for the VAS, AOFAS, and SF-12 MCS scores. The number of patients required to stabilize these curves were 21, 13, and 16, respectively. Alignment as measured by alpha and gamma angles also improved with experience, with the curves stabilizing at 18 and 15 patients, respectively. There was a larger number cases required for complication rates, with the curve stabilizing after the 39th patient. No significant learning curve was found for ankle ROM, SF-12 PCS, beta angle, tibio-talar ratio (TTR), or tibio-talar surface angle (TTS).

CONCLUSIONS

This study demonstrates a significant learning curve with respect to operative time, patient outcomes, and radiographic parameters. Extrapolating this information, we urge surgeons to adequately familiarize themselves with any new implant through a training program in a high-volume center.

LEVEL OF EVIDENCE

IV, case series.

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5–97.5%, n = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5–100%, n = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5–76%, n = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.

Evaluation of a Novel Laparoscopic Cholecystectomy Curriculum With the Use of Animal Models and Live Operating

BACKGROUND

Despite wide recognition of the benefits of simulation training, there is no established model for the teaching of laparoscopic cholecystectomy. The authors developed a replicable, intensive 2-day proficiency-based curriculum, to include simulation and live operating, designed to be practical to both attend and organize. The primary objective of this study was to evaluate this curriculum for improved procedural confidence, measured by participant self-evaluation. Secondary outcomes were objective improvement in technical skills in accordance with the Objective Structured Assessment of Technical Skills (OSATS) scale and trainee self-assessment scores.

METHODS

The course consisted of lectures, operating on a sheep hepatobiliary model through a laparoscopic box trainer, and live operating on female patient volunteers. It was attended by eight junior registrars. Precourse data collated included demographic information, experience, and procedural confidence scores using a visual analog scale. Performance on an animal model and live patient was assessed by experts using the OSATS score. Procedural confidence was re-evaluated after each task, as well as self-assessment of speed, accuracy, and overall performance.

RESULTS

Procedural confidence scores improved by a mean of 12% (P < 0.001). All trainees demonstrated sustained objective improvement in technical skills (P < 0.001). The overall mean OSATS score increased by 18%. Significant improvement was observed after performing the procedure on an animal model (P < 0.001); however, no further significant improvement was observed with live operating. No significant difference was found on trainee self-assessment scores, in any category.

CONCLUSIONS

The study describes a successful curriculum model for the teaching of laparoscopic cholecystectomy, to include procedural and technical skill acquisition, in addition to the refinement and development of procedural confidence. Importantly, this was carried out in a safe environment with direct transferability to the operating theater.

Trainee Autonomy in Minimally Invasive General Surgery in the United States: Establishing a National Benchmark

OBJECTIVE

Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation.

SETTING/PARTICIPANTS

Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible.

DESIGN

Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures.

RESULTS

A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%).

CONCLUSIONS

US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.

The Learning Curve for Thermal Ablation of Liver Cancers: 4,363-Session Experience for a Single Central in 18 Years

This study aimed to explore the special efforts required to achieve proficiency in performing thermal ablation of liver cancers, including tumors in difficult locations, and clarify the effects of handing-down teaching on the corresponding process. Major complications of patients receiving percutaneous thermal ablation of liver cancer were analyzed. Polynomial fitting was used to describe the connection between major complication rates and special experience. Learning curve of major complications was plotted both for the whole group and for each operator, respectively. Tumors in difficult locations were further studied. A total of 4,363 thermal ablation sessions were included in this study. 143 of 4,363 patients had major complications, corresponding to an incidence rate of 3.27%. 806 thermal ablation sessions were performed for tumors in difficult locations. The major complication rate of these sessions is 6.33%. According to the trend of the learning curve of the 4363 patients, the experience of the whole group can be classified into five stages, that is, the high-risk, relatively stable, unstable, proficient and stable periods. A learning curve for an individual operator can be classified into the high-risk, proficient and stable periods. The major complication rates for the chronologically first, second and third operator of the group are 3.23, 3.35, and 3.31%, respectively. The special experience needed to bypass the first stage corresponds to 410, 510, and 440 sessions, the second stage, 1850, 850, and 870 sessions, by the three operators, respectively. The major complication rates for the tumors in difficult locations for the first, second and third operator were 7.04, 5.53, and 5.98%, respectively. For the tumors in difficult locations, the special experience needed to bypass the first stage corresponds to 150, 130, and 140 sessions, the second stage, 290, 175, and 185 sessions, by the three operators, respectively. In conclusion, the learning process of an operator percutaneous thermal ablation for liver cancer can be classified into three stages. The major complication rate for tumors in difficult locations were higher than that for all tumors. Handing-down teaching can make an operator arrive at the third stage earlier but not the second stage.

UR, Jesus VHF, Jr WLC, Prolla G. Brazilian Group of Gastrointestinal Tumours' consensus guidelines for the management of gastric cancer

Gastric cancer is among the ten most common types of cancer worldwide. Most cases and deaths related to the disease occur in developing countries. Local socio-economic, epidemiologic and healthcare particularities led us to create a Brazilian guideline for the management of gastric carcinomas. The Brazilian Group of Gastrointestinal Tumors (GTG) invited 50 physicians with different backgrounds, including radiology, pathology, endoscopy, nuclear medicine, genetics, oncological surgery, radiotherapy and clinical oncology, to collaborate. This document was prepared based on an extensive review of topics related to heredity, diagnosis, staging, pathology, endoscopy, surgery, radiation, systemic therapy and follow-up, which was followed by presentation, discussion, and voting by the panel members. It provides updated evidence-based recommendations to guide clinical management of gastric carcinomas in several scenarios and clinical settings.

Lumbar MRI Reporting Efficiency for Trainees Over the Academic Year: An Opportunity for Improving Clinical Workflows in Academic Medical Centers

PURPOSE

Reporting efficiency is commonly used to measure performance and quality in diagnostic imaging. For academic centers, balancing the clinical demand for efficient reporting and educational obligation to trainees remains a major challenge. The objective of this study was to quantify the effect of trainee education on reporting efficiency over the academic year (July to June) for a single diagnostic imaging examination type.

METHODS

The authors reviewed a 10-year data set of lumbar spinal MRI reports and time-stamp data and compared change in mean reporting time for trainee versus attending radiologist-only reports. Odds ratios, linear regression, and correlation analysis were performed to evaluate relationships of mean and cumulative reporting times, volume, and study month.

RESULTS

Mean reporting time for the trainee group peaked in July (287.2 ± 4.9 min). The largest month-to-month increase was from June to July (+46.3 min, P < .01) for the trainees, and July showed the largest deviation from annualized mean reporting time (odds ratio, 1.31; 95% confidence interval, 1.16-1.47; P < .001). Mean reporting time improved linearly over the course of the academic year from July to June for trainees (R² = 0.59, P = .002), but this effect was absent in the attending radiologist-only group (P = .52).

CONCLUSIONS

This study quantifies the effect of trainee education on reporting efficiency and models the operational "learning curve" of improved performance over the academic year. These data may inform staffing and workflow improvement efforts in academic radiology departments.

Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review

BACKGROUND

Patients with typical biliary pain, no gallstones on ultrasound and low gallbladder ejection fraction (GBEF) on cholescintigraphy (gallbladder dyskinesia) may be considered for a laparoscopic cholecystectomy. However, some studies have suggested that symptoms alone are an adequate indication for laparoscopic cholecystectomy. The aim was to determine the role of cholescintigraphy in predicting outcomes of cholecystectomy in patients with typical and atypical biliary symptoms and normal biliary ultrasound.

METHODS

Meta-analysis using Preferred Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines of published literature using several electronic databases.

RESULTS

Twenty-four articles were selected with a total of 1710 patients. The majority (n = 1633, 94.4%) of patients had typical biliary symptoms. A total of 1047 patients with typical symptoms and a reduced GBEF had a cholecystectomy with 852 (81.4%) having complete resolution of symptoms. A total of 148 with typical symptoms and normal GBEF had a cholecystectomy with 103 (69.5%) having complete resolution, which was significantly less than those with a reduced GBEF (odds ratio 1.65, confidence interval 1.08-2.05, P = 0.01). Forty-five patients with atypical symptoms and a reduced GBEF had a cholecystectomy with 31 (68.9%) having complete resolution of symptoms, which is significantly lower than those with typical symptoms (odds ratio 1.97, confidence interval 0.95-3.90, P = 0.05).

CONCLUSION

Cholescintigraphy improved the predication of outcome of cholecystectomy in biliary dyskinesia by 10%. However, the presence of typical symptoms does predict an effective response in 70% of patients. Atypical symptoms predict a poorer response.

Management of Postcholecystectomy Biliary Complications: A Narrative Review

Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).

What surgical approach would provide better outcomes in children and adolescents undergoing cholecystectomy? Results of a systematic review and meta-analysis

Background

There is a lack of evidence on the surgical approach for children and adolescents undergoing cholecystectomy. Therefore, the aim of this systematic review is to compare the safety and efficacy of minimally invasive cholecystectomy to open cholecystectomy in children and/or adolescents.

Main body

A search was conducted on MEDLINE, PubMed, Cochrane and Embase from inception to October 2018. We included comparative studies investigating outcomes following robotic-assisted, laparoscopic and/or open cholecystectomy in children and/or adolescents. The outcomes of interest included post-operative complication rate, operation time, length of hospital stay, post-operative pain and conversion to open procedure. The Newcastle-Ottawa Scale was used to assess the risk of bias. Meta-analysis was performed using random-effect models.

Twenty-one studies were included involving 927 children and/or adolescents. All, but one, compared outcomes between laparoscopic versus open cholecystectomy. The great majority of the included studies presented a low risk of bias. Patients undergoing laparoscopic cholecystectomy had less post-operative complications (RR: 0.57; 95%CI 0.35 to 0.94), reduced length of hospital stay (MD − 3.73; 95%CI − 4.88 to − 2.59), but longer operative time (MD 26.61; 95%CI 9.35 to 43.86) when compared to open cholecystectomy. The average conversion from laparoscopic to open cholecystectomy was 7% across studies.

Conclusions

The current evidence suggested that laparoscopic cholecystectomy in children and/or adolescents is safe resulting in lower rates of postoperative complications and length of stay, but longer operative times, when compared to the open approach.

PROSPERO registration

CRD42017067641

Level of evidence

Level III

Learning curves of open and endoscopic fetal spina bifida closure: systematic review and meta-analysis

OBJECTIVE

The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques.

METHODS

MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only if they reported outcome variables necessary to measure the LC, as defined by fetal safety and efficacy. Two authors independently retrieved data, assessed the quality of the studies and categorized observations into blocks of 30 patients. For meta-analysis, data were pooled using a random-effects model when heterogeneous. To measure the LC, we used two complementary methods. In the group-splitting method, competency was defined when the procedure provided results comparable to those in the MOMS trial for 12 outcome variables representing the immediate surgical outcome, short-term neonatal neuroprotection and long-term neuroprotection at ≥ 12 months of age. Then, when raw patient data were available, we performed cumulative sum analysis based on a composite binary outcome defining successful surgery. The composite outcome combined four clinically relevant variables for safety (absence of extreme preterm delivery < 30 weeks, absence of fetal death ≤ 7 days after surgery) and efficacy (reversal of hindbrain herniation and absence of any neonatal treatment of dehiscence or cerebrospinal fluid leakage at the closure site).

RESULTS

Of 6024 search results, 17 (0.3%) studies were included, all of which had low, moderate or unclear risk of bias. Fetal SBA closure was performed using standard hysterotomy (11 studies), mini-hysterotomy (one study) or fetoscopy by either exteriorized-uterus single-layer closure (one study), percutaneous single-layer closure (three studies) or percutaneous two-layer closure (one study). Only outcomes for standard hysterotomy could be meta-analyzed. Overall, outcomes improved significantly with experience. Competency was reached after 35 consecutive cases for standard hysterotomy and was predicted to be achieved after ≥ 57 cases for mini-hysterotomy and ≥ 56 for percutaneous two-layer fetoscopy. For percutaneous and exteriorized-uterus single-layer fetoscopy, competency was not reached in the 81 and 28 cases available for analysis, respectively, and LC prediction analysis could not be performed.

CONCLUSIONS

The number of cases operated is correlated with the outcome of fetal SBA closure, and the number of operated cases required to reach competency ranges from 35 for standard hysterotomy to ≥ 56-57 for minimally invasive modifications. Our observations provide important information for institutions looking to establish a new fetal center, develop a new fetal surgery technique or train their team, and inform referring clinicians, potential patients and third parties. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Video Coaching Improving Contemporary Technical and Nontechnical Ability in Laparoscopic Education

OBJECTIVE

A video coaching (VC) system has been developed in surgical education. This study compares the educational effect on technical and nontechnical skills of the VC method for teaching laparoscopic surgery.

DESIGN

We conducted a prospectively randomized study of an education program to teach laparoscopic procedures.

SETTING

The study was performed at the Chang Gung Memorial Hospital, a university hospital in Taiwan.

PARTICIPANTS

We enrolled sixteen first- or second-year surgical residents.The participants were randomized into VC and conventional teaching (CT) groups, and their surgical skills were judged by the Global Operation Assessment of Laparoscopic Skills (GOALS) and the Objective Structured Assessment of Technical Skills (OSATS). Nontechnical skills were evaluated by the Non-Technical Skills for Surgeons (NOTSS) assessment and self-efficacy questionnaires (SEQs). After the program, posttraining scores were compared to assess improvements.

RESULTS

The 16 enrolled participants finished the entire course and completed all the videos during the study period. Comparing the VC and CT groups, we found that the pretraining GOALS, OSATS, NOTSS and SEQ scores were similar between both groups. However, after training, the OSATS score gain was higher in the VC groupthan in the CT group (9.25 ± 2.05 vs. 6.50 ± 1.51, p=0.009). Regarding nontechnical skills, the NOTSS score improved more in the VC group than in the CT group (5.50 ± 0.93 vs. 4.25 ± 0.89, p=0.015). The SEQ score was also higher in the VC group (32.13 ± 2.10) than in the CT group (29.50 ± 1.77), with a significant difference (p=0.018).

CONCLUSION

VC can help surgeons build their expertise using a more accessible method. Additionally, VC can shorten the learning curve and improve self-efficacy, thereby contributing to surgeons' education.

An Alternative Technique in Laparoscopic Cholecystectomies: Removal Without a Specimen Bag

The use of specimen retrieval bags in elective laparoscopic cholecystectomies remains a customary practice intended to reduce surgical site infections. The lack of supporting evidence suggests that specimen bags may not be necessary. Thus, we present an alternative approach without the use of disposable instruments to reduce excessive healthcare costs while maintaining comparable surgical outcomes.

Validation of a Novel Needle Holder to Train Advanced Laparoscopy Skills to Novices in a Simulator Environment

Background. Our aim was to determine if a newly designed Najar needle holder (NNH) shortens the time for novices to improve advanced laparoscopy (AL) techniques (suturing/knot tying), compared with a conventional macro needle holder (MNH) in a simulator. Furthermore, we aimed to validate a new video scoring system determining AL skills. Methods. Forty-six medical students performed identical surgical tasks in a prospective, crossover study evaluating AL skills (NNH vs MNH). All subjects performed a double-throw knot, 2 single-throw knots following 3 running sutures in the Simball Box (SB) simulator. After resting, subjects switched needle holders. All tasks were videotaped and analyzed using SB software and by 2 independent reviewers using the Objective Video Evaluation Scoring Table (OVEST). Trial performance expressed as SB Overall Score (SBOS) and OVEST. Results. In the group starting with NNH (followed by MNH) OVEST was consistently high during both trials (median = 12.5, range = 6.5-18.0, and median = 13.5, range = 6.5-21.0; P = .2360). However, in the group starting with MNH, OVEST improved significantly when the participants changed to NNH (median = 10.0, range = 2.5-19.5, vs median = 14.5, range = 4.5-18.0; P = .0003); an improvement was also found with SBOS (median = 37%, range = 27% to 92%, vs median = 48%, range = 34% to 70%; P = .0289). In both trials, both independent reviewers' OVEST measures correlated well: Trial 1: β = 0.97, P < .0001; and Trial 2: β = 0.95, P < .0001. A correlation also existed between SBOS and OVEST in both trials (β = 2.1, P < .0001; and β = 1.9, P = .0002). Conclusions. This study indicates a significantly higher improvement in laparoscopic suturing skills in novices training AL skills using NNH compared with MNH. Starting early, AL training in novices using NNH is a feasible option. Furthermore, OVEST used in experimental settings as an evaluation tool is comparable with the validated SBOS.

Trainee Performance After Laparoscopic Simulator Training Using a Blackbox versus LapMentor

BACKGROUND

Training using laparoscopic high-fidelity simulators (LHFSs) to proficiency levels improves laparoscopic cholecystectomy skills. However, high-cost simulators and their limited availability could negatively impact residents' laparoscopic training opportunities. We aimed to assess whether motivation and surgical skill performance differ after basic skills training (BST) using a low-cost (Blackbox) versus LHFS (LapMentor) among medical students.

MATERIALS AND METHODS

Sixty-three medical students from Karolinska Institutet volunteered, completing written informed consent, questionnaire regarding expectations of the simulation training, and a visuospatial ability test. They were randomized into two groups that received BST using Blackbox (n = 32) or LapMentor (n = 31). However, seven students absence resulted in 56 participants, followed by another 9 dropouts. Subsequently, after training, 47 students took up three consecutive tests using the minimally invasive surgical trainer-virtual reality (MIST-VR) simulator, finalizing a questionnaire.

RESULTS

More Blackbox group participants completed all MIST-VR tests (29/31 versus 18/25). Students anticipated mastering LapMentor would be more difficult than Blackbox (P = 0.04). In those completing the simulation training, a trend toward an increase was noted in how well participants in the Blackbox group liked the simulator training (P = 0.07). Subgroup analysis of motivation and difficulty in liking the training regardless of simulator was found only in women (Blackbox [P = 0.02]; LapMentor [P = 0.06]). In the Blackbox group, the perceived difficulty of training, facilitation, and liking the Blackbox training (significant only in women) were significantly correlated with the students' performance in the MIST-simulator. No such correlations were found in the LapMentor group.

CONCLUSIONS

Results indicate an important role for low-tech/low-cost Blackbox laparoscopic BST of students in an otherwise high-tech surrounding. Furthermore, experience of Blackbox BST procedures correlate with students' performance in the MIST-VR simulator, with some gender-specific differences.

Survey of Basic Laparoscopic Training Exposure of Nigerian Postgraduate Trainees

Background:

The practice of laparoscopy involves the use of training models that are different from conventional open surgery. These concepts are not captured in the traditional models of surgical residency training. Residency training in surgery has been seen as an ample opportunity for early introduction and training in laparoscopy.

Objectives:

This study aimed to assess the level of exposure and training experience of some surgical resident doctors in accredited training institutions in Nigeria on laparoscopy.

Methodology:

A cross-sectional survey was conducted among the resident doctors undergoing revision course in surgery at the National Orthopaedic Hospital, Igbobi, Lagos, and Lagos University Teaching Hospital, Lagos, in March 2018. Using the quantitative method of data collection, a pre-tested structured questionnaire was used to collect information on the demography and training exposure of the residents in laparoscopy.

Results:

A total of 54 of 96 residents surveyed returned the questionnaire, giving a response rate of 56%. There were 53 (98.1%) males and 1 (1.9%) female. The age range of the respondents was between 30 and 46 years, with a mean of 34.2 ± 3.96 years. Thirty-two (59.3%) respondents had spent at least 2 years training in surgery. Thirty-six (66.7%) respondents had not participated in more than four laparoscopic procedures during their rotation. Forty-six percent of respondents reported that their experience in laparoscopy was mainly by observation of the procedures. Forty-nine (90.7%) of respondents surveyed had not attended any training program in laparoscopy. Eighty-one (81.0%) of respondents had a strong motivation and desire for future practice of laparoscopy.

Conclusion:

This study revealed that few Nigerian postgraduate trainees sampled in the survey were exposed and had training experience in laparoscopy.

A global perspective on implant education: Cluster analysis of the "first dental implant experience" of dentists from 84 nationalities

OBJECTIVES

The aim of this cross-sectional study was to explore the demographic and educational patterns related to the dentists' first implant dental experience.

MATERIAL AND METHODS

Participants of a Massive Open Online Course in implant dentistry who have placed and restored implants completed a 25-item online questionnaire investigating their pathway of education and assessing their experience with the "first implant placement." Exploratory analysis included hierarchical clustering using 9 demographic categorical factors.

RESULTS

A total of 1015 respondents from 84 countries formed 5 distinct clusters. Age and work experience were dominant clustering traits, decreasing from Cluster 1 to Cluster 5. Clusters 1 and 3 represented "senior" and "younger" general dental practitioners, respectively, whilst Clusters 2 and 4 represented post-graduate educated clinicians. Cluster 5 represented recent graduates. Asia, South America and Africa were over-represented in "younger" clusters. Time in practice was a significant determinant of attitudes, followed by completion of post-graduate education. There were significant differences in reported patterns of challenges and complications depending on dentists' time in practice, age and post-graduate education. Challenge in implant positioning was more frequently identified by "young post-graduate" educated dentists. Recent graduates reported having the fewest complications of all clusters. Obtaining implant education in University settings was most frequently recommended by clusters of dentists with post-graduate education.

CONCLUSIONS

Time in practice is a parameter to be considered when designing implant education. The absence of structured education and mentorship might lead to inability to properly assess treatment outcomes and identify complications. Quality-assured and practice-directed education is needed at a global level, to support in particular, recent graduates who now seem to engage with implant dentistry early in their career.

Classification of Intermediate and Novice Surgeons' Skill Assessment Through Performance Metrics

Background. Endoscopic surgeries have become an alternative for open procedures whenever possible. For such types of operations, surgeons are required to gain several skills, whose development needs hands-on practice. Accordingly, gaining these skills today is a challenge for surgical education programs. Despite the development of several technology-enhanced training environments, there are still problems to better integrate these technologies into educational programs. For an appropriate integration, it is critical to assess the skill levels and adapt the training content according to the trainees' requirements. In the literature, there exist several methods for assessing these skill levels. However, there are still problems in practice for objective and repetitive assessment. Methods. The present study aims to estimate the skill levels of participants in surgical training programs in an objective manner by collecting experimental data from residents in an endoscopic surgical simulation environment and gathering performance metrics. Results. It is shown that, by comparing the results of a number of classification algorithms for the best accuracy estimation and feature set, the "novice" and "intermediate" skill levels can be estimated with an accuracy of 86%. Conclusions. The outcomes help surgical educators and instructional system designers to better assess the skill levels of the trainees and guide them accordingly. In addition, objective assessments as highlighted in this study can be beneficial when designing technology-enhanced adaptive learning environments.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."