Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections

Learning curve of ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery: a cumulative sum analysis

Purpose

To identify the learning curve in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery.

Methods

Data consist of consecutively ordered patients who underwent ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery between May 2020 and June 2023. The learning curve of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery was measured in terms of the operating time adjusted by multivariate linear regression. A cumulative sum analysis was performed to establish the learning curve. Patients' characteristics and surgical outcomes were compared based on the inflection points of this curve.

Results

The learning curve was divided into two unique phases: phase 1 (1-26 patients), and phase 2 (27-40 patients). The expected operating time in phase 2 was shorter than in phase 1 (86.4 ± 11.2 min vs. 102.0 ± 22.7 min, p = 0.021). The time to first postoperative flatus was shorter in phase 2 compared with phase 1 (14.6 ± 6.5 h vs. 20.6 ± 6.3 h, respectively, p = 0.008). No significant differences were observed in terms of patient's age, BMI, tumor size, parity, bilateral ovarian tumor, pathological diagnoses, estimated blood loss, postoperative pain score, or perioperative complications between the two phases.

Conclusion

Proficiency in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery was achieved after 26 surgeries based on cumulative sum analysis. These findings may provide insight for structured training programs of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery.

The transition of surgical simulation training and its learning curve: a bibliometric analysis from 2000 to 2023

BACKGROUND

Proficient surgical skills are essential for surgeons, making surgical training an important part of surgical education. The development of technology promotes the diversification of surgical training types. This study analyzes the changes in surgical training patterns from the perspective of bibliometrics, and applies the learning curves as a measure to demonstrate their teaching ability.

METHOD

Related papers were searched in the Web of Science database using the following formula: TS=[(training OR simulation) AND (learning curve) AND (surgical)]. Two researchers browsed the papers to ensure that the topics of articles were focused on the impact of surgical simulation training on the learning curve. CiteSpace, VOSviewer, and R packages were applied to analyze the publication trends, countries, authors, keywords, and references of selected articles.

RESULT

Ultimately, 2461 documents were screened and analyzed. The USA is the most productive and influential country in this field. Surgical endoscopy and other interventional techniques publish the most articles, while surgical endoscopy and other interventional techniques is the most cited journal. Aggarwal Rajesh is the most productive and influential author. Keyword and reference analyses reveal that laparoscopic surgery, robotic surgery, virtue reality, and artificial intelligence were the hotspots in the field.

CONCLUSION

This study provided a global overview of the current state and future trend in the surgical education field. The study surmised the applicability of different surgical simulation types by comparing and analyzing the learning curves, which is helpful for the development of this field.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group)

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Evaluating the surgical trainee ergonomic experience during minimally invasive abdominal surgery (ESTEEMA study)

Minimally invasive abdominal surgery (MAS) can exert a physical cost. Surgical trainees spend years assisting minimally-invasive surgeries, increasing the risk of workplace injury. This prospective questionnaire-based cohort study was conducted amongst general surgery residents in Singapore. Residents assisting major MAS surgery were invited to complete anonymous online survey forms after surgery. The Phase 1 survey assessed physical discomfort scores and risk factors. Intraoperative measures to improve ergonomics were administered and evaluated in Phase 2. During Phase 1 (October 2021 to April 2022), physical discomfort was reported in at least one body part in 82.6% (n = 38) of respondents. Over a third of respondents reported severe discomfort in at least one body part (n = 17, 37.0%). Extremes of height, training seniority, longer surgical duration and operative complexity were significant risk factors for greater physical discomfort. In Phase 2 (October 2022 to February 2023), the overall rate of physical symptoms and severe discomfort improved to 81.3% (n = 52) and 34.4% (n = 22) respectively. The ergonomic measure most found useful was having separate television monitors for the primary surgeon and assistants, followed by intraoperative feedback on television monitor angle or position. Close to 20% of survey respondents felt that surgeon education was likely to improve physical discomfort.

Short- and long-term outcome differences between patients undergoing left and right colon cancer surgery: cohort study

PURPOSE

Since the literature currently provides controversial data on the postoperative outcomes following right and left hemicolectomies, we carried out this study to examine the short- and long-term treatment outcomes.

METHODS

This study included consecutive patients who underwent right or left-sided colonic resections from year 2014 to 2018 and then they were followed up. The short-term outcomes such as postoperative morbidity and mortality according to Clavien-Dindo score, duration of hospital stay, and 90-day readmission rate were evaluated as well as long-term outcomes of overall survival and disease-free survival. Multivariable Cox regression analysis was performed of overall and progression-free survival.

RESULTS

In total, 1107 patients with colon tumors were included in the study, 525 patients with right-sided tumors (RCC) and 582 cases with tumors in the left part of the colon (LCC). RCC group patients were older (P < 0.001), with a higher ASA score (P < 0.001), and with more cardiovascular comorbidities (P < 0.001). No differences were observed between groups in terms of postoperative outcomes such as morbidity and mortality, except 90-day readmission which was more frequent in the RCC group. Upon histopathological analysis, the RCC group's patients had more removed lymph nodes (29 ± 14 vs 20 ± 11, P = 0.001) and more locally progressed (pT3-4) tumors (85.4% versus 73.4%, P = 0.001). Significantly greater 5-year overall survival and disease-free survival (P = 0.001) were observed for patients in the LCC group, according to univariate Kaplan-Meier analysis.

CONCLUSIONS

Patients with right-sided colon cancer were older and had more advanced disease. Short-term surgical outcomes were similar, but patients in the LCC group resulted in better long-term outcomes.

Training and assessment for colorectal surgery and appendicectomy- a systematic review

AIM

There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach.

METHOD

A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported.

RESULTS

Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery.

CONCLUSION

This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

Arthroscopic Anterior Cruciate Ligament Reconstruction Learning Curve: Analysis of Operating Time and Clinical Outcomes

Background

Technical proficiency for arthroscopic anterior cruciate ligament reconstruction (ACLR) is complex and requires learning and practice. Achieving an appropriate level of competency with this surgery is important for patient safety and satisfactory surgical outcomes. There is limited literature about the learning curve in ACLR in Africa.

Objectives

This study aimed to demonstrate the learning curve associated with ACLR.

Materials and Methods

This retrospective study on arthroscopic ACLR was conducted between January 2020 and June 2023 with a minimum of 12 months follow-up. The primary outcome measure was operation time, whereas the secondary outcome measures were functional outcome and postoperative complications.

Results

One hundred fifty-nine ACLR met the inclusion criteria and were analysed. The mean age of the patients was 31.47 ± 9.50 years. There were 148 (93.1%) males and 11 (6.9%) females. The median operation time was 50 min (45-190 min). There was progressively decreasing operation time with increasing number of cases done until after the first 19 cases. The mean operating time for the first 19 cases was 143.89 ± 32.84 min, whereas the mean operating time for the later 140 cases was 53.81 ± 9.72 min (P = 0.000).

Conclusions

The operation time for arthroscopic ACLR progressively decreased until after the first 19 cases. There was, however, no significant difference in the clinical outcome between the cases done during the learning curve and those done at proficiency.

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience

BACKGROUND

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections.

METHODS

In 2013, a laparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study.

RESULTS

A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17 cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94 patients (84%). Among the complications, wound infection was seen in seven patients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively.

CONCLUSION

This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

An analysis of virtual reality in abdominal surgery-A scoping review

BACKGROUND

The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity.

METHODS

A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine.

RESULTS

Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training.

CONCLUSIONS

Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

The learning curve for laparoscopic pancreaticoduodenectomy by a proficient laparoscopic surgeon: a retrospective study at a single center

BACKGROUND

To explore the learning curve of single center laparoscopic pancreaticoduodenectomy (LPD) and evaluate the safety and efficacy of the operation at different stages.

METHODS

A detailed review was conducted on the clinical data of 120 cases of laparoscopic pancreatoduodenectomy performed by the same surgeon between June 2018 and June 2022. Cases that did not provide insights into the learning curve of the procedure were excluded. The cumulative sum (CUSUM) analysis and the best fitting curve methods were employed to delineate the learning curve based on operation time and intraoperative blood loss. The study further evaluated the number of surgeries required to traverse the learning curve. Outcome measures, including operation time, intraoperative blood loss, length of stay, complications, and other relevant indicators, were extracted and compared across different phases of the learning curve.

RESULT

The maximum turning point of the fitting curve was found in 35 cases by the cumulative sum method of operation time, after which the learning curve could be considered to have passed. The fitting curve obtained by the cumulative sum method of intraoperative blood loss was stable in 30 cases and proficient in 60 cases, which was basically consistent with the fitting curve of operation time. Taking 35 cases as the boundary, the learning curve is divided into learning improvement stage and mastering stage. There was no statistical significance in the general data of the two stage patients (P > 0.05). Hospitalization days decreased from 19 to 15 days (P < 0.05);Pancreatic fistula decreased from 20.0% of grade B and 8.6% of grade C to 7.1% of grade B and 3.5% of grade C (P < 0.05), and the operative time decreased from (376.9 ± 48.2) minutes to (294.4 ± 18.7) minutes (P < 0.05). Intraoperative blood loss decreased from 375 to 241 ml (P < 0.05).

CONCLUSION

Thirty-five patients with LPD can reach the proficiency stage and the perioperative indexes can be improved.

A 10-year review on older patients undergoing colorectal cancer surgery: surgeon-led geriatric service and good quality surgery are drivers of good outcomes

BACKGROUND

Older age and frailty are associated with worse postoperative outcomes and prolonged length of stay (LOS). In this study, we aimed to analyze the long-term outcomes after the implementation of our geriatric surgical service (GSS).

METHODS

This was a single-center retrospective study from July 2010 to December 2021 on patients aged ≥75 years or patients aged ≥65 years with frailty. Our GSS includes multidisciplinary assessment and optimization by specialized nurses, physiotherapists, anesthetists, dietitians, and geriatricians. Cumulative sum (CUSUM) analysis was used to assess the performance of our GSS. Our primary outcome was defined as the presence of 30-day mortality, prolonged LOS ≥ 14 days, and/or >10% decrease in the modified Barthel Index at 6 weeks, which depicts the failure of GSS. A downsloping CUSUM curve implies consecutive cases of success.

RESULTS

There were 233 patients with a mean age of 79.0 ± 4.9 years; of these, 73 patients (31.3%) were frail. The overall 30-day mortality (1.7%), Clavien-Dindo ≥ grade IIIA complications (12.0%), and LOS (median, 7.0 days) were low. The CUSUM analysis showed 3 phases with overall sustained improvement in outcomes. Transient inconsistency in the second phase (during midimplementation of GSS) may be due to the early adoption of laparoscopic surgery (44.6% vs 24.1%; adjusted P =.031) and expansion of service to include patients with higher perioperative risks (weighted Charlson Comorbidity Index score ≥4: 64.9% vs 38.0%; adjusted P =.002) in the second period compared with the first period. The outcomes subsequently improved in the third phase after overcoming the learning curve.

CONCLUSION

Our GSS showed sustained performance over the past decade. Good quality surgery and surgeon-led geriatric service are paramount for good postoperative outcomes.

Transition from laparoscopic to robotic approach in rectal cancer: a single-center short-term analysis based on the learning curve

As a novel procedure becomes more and more used, knowledge about its learning curve and its impact on outcomes is useful for future implementations. Our aim is (i) to identify the phases of the robotic rectal surgery learning process and assess the safety and oncological outcomes during that period, (ii) to compare the robotic rectal surgery learning phases outcomes with laparoscopic rectal resections performed before the implementation of the robotic surgery program. We performed a retrospective study, based on a prospectively maintained database, with methodological quality assessment by STROBE checklist. All the procedures were performed by the same two surgeons. A total of 157 robotic rectal resections from June 2018 to January 2022 and 97 laparoscopic rectal resections from January 2018 to July 2019 were included. The learning phase was completed at case 26 for surgeon A, 36 for surgeon B, and 60 for the center (both A & B). There were no differences in histopathological results or postoperative complications between phases, achieving the same ratio of mesorectal quality, circumferential and distal resection margins as the laparoscopic approach. A transitory increase of major complications and anastomotic leakage could occur once overcoming the learning phase, secondary to the progressive complexity of cases. Robotic rectal cancer surgery learning curve phases in experienced laparoscopic surgeons was completed after 25-35 cases. Implementation of a robotic rectal surgery program is safe in oncologic terms, morbidity, mortality and length of stay.

Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach

PURPOSE

Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study was to evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches.

METHODS

Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage 3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches.

RESULTS

There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade 3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1 ml vs. 137.6 ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54).

CONCLUSIONS

Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this.

PROSPERO ID

CRD42021287065.

Comparison of surgical outcomes between robot-assisted laparoscopic hysterectomy and conventional total laparoscopic hysterectomy in gynecologic benign disease: a single-center cohort study

We compared the surgical outcomes of robot-assisted laparoscopic hysterectomy (RAH) and total laparoscopic hysterectomy (TLH). This single-center cohort study compared 139 RAH cases from January, 2017 to September, 2021 and 291 TLH cases between January, 2015 and December, 2020. We retrospectively evaluated surgical outcomes, including total operative time (defined as the time from port wound incision to port wound closure), net operative time (defined as the time from the start of pneumoperitoneum to the end of pneumoperitoneum), estimated blood loss, weight of excised uterus (±adnexa), and overall complications, and the relationship between surgeon experience and operative time, net operative time, and blood loss in RAH and TLH. There was no significant difference in the total operative time between the two groups. Regardless of surgeon experience, the net operative time was significantly shorter in the RAH group than in the TLH group (p <0.001) and the estimated blood loss was significantly lower in RAH cases than in TLH cases (p = 0.01). The net operative time per uterine weight was shorter in the TLH group than that in the RAH group; however, there was no significant difference. RAH resulted in statistically better surgical outcomes in terms of net operative time and blood loss, regardless of surgeon experience. However, net operative time and blood loss also seem to be significantly affected by uterus weight. Large trials are imperative to determine the more effective surgical approach between RAH and TLH for different patient subsets.

Factors associated with conversion in laparoscopic surgery in a low-resource setting: a single-center prospective study

INTRODUCTION

Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting.

METHODS

This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate.

RESULTS

A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11-75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1-16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002).

CONCLUSION

A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings.

Minimally Invasive Colorectal Surgery Techniques

Colorectal surgery has witnessed a transformative shift with the advent of minimally invasive techniques, offering patients reduced postoperative discomfort, shorter hospital stays, and accelerated recovery compared to conventional open surgery. This comprehensive review aims to assess the current state of minimally invasive approaches in colorectal surgery, encompassing various techniques such as single-incision laparoscopic surgery, robot-assisted surgery, and conventional laparoscopic surgery. The article meticulously explores the benefits and drawbacks of each technique, delves into the established criteria for their application, delineates cautious circumstances, and analyzes the outcomes of minimally invasive colorectal surgery. Additionally, the integration of virtual reality and augmented reality for surgical planning and training is discussed, shedding light on the future trajectory of this field. Surgeons and researchers striving to enhance patient care and surgical outcomes in colorectal surgery will find this review article an invaluable resource, presenting crucial components of minimally invasive colorectal surgery and paving the way for continued advancements in the field.

Analysis of the Impact of the Learning Curve on the Safety Outcome of the Totally Robotic-Assisted Biliopancreatic Diversion with Duodenal Switch: a Single-Institution Observational Study

INTRODUCTION

Totally robotic-assisted biliopancreatic diversion with duodenal switch (BPD/DS) learning curve has been described to be longer at approximately 50 cases, at which point operative time and complications rate decrease and tend to stabilize. This study aimed to form an analysis of the impact of the learning curve on the safety outcomes of the totally robotic-assisted BPD/DS.

METHODS

A retrospective review of patients who underwent primary totally robotic-assisted BPD/DS by one of our certified bariatric and metabolic surgeon member of our institution was performed. The patients were classified into two groups, the learning stage group (first 50 cases) and the mastery stage group. Differences in operative time in minutes and postoperative outcomes were analyzed.

RESULTS

Two hundred seventy-six patients were included. The operative time and the postoperative length of stay were significantly higher in the learning stage group (173.8 ± 35.8 min vs. 139.2 ± 30.2 min, p= 0.0001; 3.4 ± 1.4 days vs. 2.6 ± 0.9 days, p= 0.0002). The overall leakage rate was significantly higher in the learning stage group (8% vs. 0.4%, p= 0.0001). The global rate of complications for the learning stage group was 14%, and for the mastery stage group was 6.6% (p= 0.08).

CONCLUSIONS

After the first 50 cases, the operative time, the length of stay, and the overall rate of complications decreased, being especially significant the decrease in the duodeno-ileal anastomosis leakage rate after reaching the learning curve.

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.

Robot-Assisted versus Laparoscopic Gastrointestinal Surgery: A Systematic Review and Metanalysis of Intra- and Post-Operative Complications

BACKGROUND

The use of robotic surgery is attracting ever-growing interest for its potential advantages such as small incisions, fine movements, and magnification of the operating field. Only a few randomized controlled trials (RCTs) have explored the differences in perioperative outcomes between the two approaches.

METHODS

We screened the main online databases from inception to May 2023. We included studies in English enrolling adult patients undergoing elective gastrointestinal surgery. We used the following exclusion criteria: surgery with the involvement of thoracic esophagus, and patients affected by severe heart, pulmonary and end-stage renal disease. We compared intra- and post-operative complications, length of hospitalization, and costs between laparoscopic and robotic approaches.

RESULTS

A total of 18 RCTs were included. We found no differences in the rate of anastomotic leakage, cardiovascular complications, estimated blood loss, readmission, deep vein thrombosis, length of hospitalization, mortality, and post-operative pain between robotic and laparoscopic surgery; post-operative pneumonia was less frequent in the robotic approach. The conversion to open surgery was less frequent in the robotic approach, which was characterized by shorter time to first flatus but higher operative time and costs.

CONCLUSIONS

The robotic gastrointestinal surgery has some advantages compared to the laparoscopic technique such as lower conversion rate, faster recovery of bowel movement, but it has higher economic costs.

The SUPER reporting guideline suggested for reporting of surgical technique: explanation and elaboration

Background

Surgical technique plays an essential role in achieving good health outcomes. However, the quality of surgical technique reporting remains heterogeneous. Reporting checklists could help authors to describe the surgical technique more transparently and effectively, as well as to assist reviewers and editors evaluate it more informatively, and promote readers to better understand the technique. We previously developed SUPER (surgical technique reporting checklist and standards) to assist authors in reporting their research that contains surgical technique more transparently. However, further explanation and elaboration of each item are needed for better understanding and reporting practice.

Methods

We searched surgical literature in PubMed, Google Scholar and journal websites published up to January 2023 to find multidiscipline examples in various article types for each SUPER item.

Results

We explain the 22 items of the SUPER and provide rationales item by item alongside. We provide 69 examples from 53 literature that present optimal reporting of the 22 items. Article types of examples include pure surgical technique, and case reports, observational studies and clinical trials that contain surgical technique. Examples are multidisciplinary, including general surgery, orthopaedical surgery, cardiac surgery, thoracic surgery, gastrointestinal surgery, neurological surgery, oncogenic surgery, and emergency surgery etc.

Conclusions

Along with SUPER article, this explanation and elaboration file can promote deeper understanding on the SUPER items. We hope that the article could further guide surgeons and researchers in reporting, and assist editors and peer reviewers in reviewing manuscripts related to surgical technique.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Meta‑analysis of randomized controlled trials comparing intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: upgrading the level of evidence

BACKGROUND

Minimally invasive right hemicolectomy has been increasingly used for the treatment of right hemicolectomy disease, and both intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) are available to restore intestinal continuity. However, the advantages and disadvantages of these two anastomoses are highly controversial. The present meta-analysis evaluated the effectiveness of ICA versus ECA in minimally invasive right colectomy to improve the grade of evidence.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) comparing intracorporeal versus extracorporeal anastomosis in laparoscopic or robotic right hemicolectomy published from database inception to February 2023. Two researchers performed the literature review, data extraction, bias assessment, and meta-analysis of the data using Review Manager 5.4 software.

RESULTS

Seven RCTs with a total of 750 patients were included in the meta-analysis. The results showed a lower incidence of postoperative paralytic ileus (RR 0.62, 95% CI 0.39 ~ 0.99, p = 0.04) and shorter incision length (MD - 1.38; 95% CI: - 1.98 ~  - 0.78, p < 0.00001), but longer operative time (MD 10.69; 95% CI: 2.76 ~ 18.63, p = 0.008). The remaining events including bleeding (RR 0.49, 95% CI: 0.12 ~ 2.04, p = 0.33), anastomotic leak (RR 0.62, 95% CI: 0.39 ~ 0.99, p = 0.85), surgical site infection (RR 0.15, 95% CI: 0.22 ~ 1.25, p = 0.15), overall perioperative morbidity (RR 0.86, 95% CI: 0.58 ~ 1.26, p = 0.44), number of harvested lymph nodes (MD 0.75; 95% CI: - 0.15 ~ 1.65, p = 0.10), and length of hospital stay (MD - 0.27; 95% CI: - 0.91 ~ 0.38, p = 0.42) were not statistically significant.

CONCLUSIONS

Compared to ECA, ICA in minimally invasive right hemicolectomy reduced the risk of postoperative paralytic ileus and shortened the length of the incision but prolonged the operative time.

Retrospective analysis of surgical and oncological results of laparoscopic surgeries performed by residents of coloproctology

INTRODUCTION

with the improvement and wide acceptance of laparoscopy in colorectal operations, there was a need for specific training of surgeons in training. There are few studies evaluating the postoperative results of laparoscopic colectomies performed by resident physicians and their impact on patient safety.

PURPOSE

to analyze the surgical and oncological results of laparoscopic colectomies performed by coloproctology residents and compare them with data in the literature.

METHODS

this is a retrospective analysis of patients undergoing laparoscopic colorectal surgery performed by resident physicians at the Hospital das Clínicas de Ribeirão Preto, between 2014 and 2018. The clinical characteristics of the patients were studied, as well as the main surgical and oncological aspects in a period of one year.

RESULTS

we analyzed 191 operations, whose main surgical indication was adenocarcinoma, most of them stage III. The mean duration of surgeries was 210±58 minutes. There was a need for a stoma in 21.5% of the patients, mainly loop colostomy. The conversion rate was 23%, with 79.5% due to technical difficulties, and the main predictors of conversion were obesity and intraoperative accidents. The median length of stay was 6 days. Preoperative anemia was associated with a higher rate of complications (11.5%) and reoperations (12%). Surgical resection margins were compromised in 8.6% of cases. The one-year recurrence rate was 3.2% and the mortality rate was 6.3%.

CONCLUSIONS

videolaparoscopic colorectal surgery performed by residents showed efficacy and safety similar to data found in the literature.

Assessment methods in laparoscopic colorectal surgery: a systematic review of available instruments

BACKGROUND

Laparoscopic surgery has become the golden standard for many procedures, requiring new skills and training methods. The aim of this review is to appraise literature on assessment methods for laparoscopic colorectal procedures and quantify these methods for implementation in surgical training.

MATERIALS AND METHODS

PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in October 2022 for studies reporting learning and assessment methods for laparoscopic colorectal surgery. Quality was scored using the Downs and Black checklist. Included articles were categorized in procedure-based assessment methods and non-procedure-based assessment methods. A second distinction was made between capability for formative and/or summative assessment.

RESULTS

In this systematic review, nineteen studies were included. These studies showed large heterogeneity despite categorization. Median quality score was 15 (range 0-26). Fourteen studies were categorized as procedure-based assessment methods (PBA), and five as non-procedure-based assessment methods. Three studies were applicable for summative assessment.

CONCLUSIONS

The results show a considerable diversity in assessment methods with varying quality and suitability. To prevent a sprawl of assessment methods, we argue for selection and development of available high-quality assessment methods. A procedure-based structure combined with an objective assessment scale and possibility for summative assessment should be cornerstones.

The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease

BACKGROUND

As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field.

RESULTS

The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve.

CONCLUSIONS

The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

Surgical efficacy and learning curves of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: A retrospective two-center cohort study

BACKGROUND

There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons.

METHODS

A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM).

RESULTS

A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0]).

CONCLUSION

The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time.

Short term results in a population based study indicate advantage for laparoscopic colon cancer surgery versus open

The aim of this study was to compare LAP with OPEN regarding short-term mortality, morbidity and completeness of the cancer resection for colon cancer in a routine health care setting using population based register data. All 13,683 patients who were diagnosed 2012-2018 and underwent elective surgery for right-sided or sigmoid colon cancer were included from the Swedish Colorectal Cancer Registry and the National Patient Registry. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, length of hospital stay, reoperation, readmission and positive resection margin (R1). Weighted and unweighted multi regression analyses were performed. There were no difference in 30-day mortality: LAP (0.9%) and OPEN (1.3%) (OR 0.89, 95% CI 0.62-1.29, P = 0.545). The weighted analyses showed an increased 90-day mortality following OPEN, P < 0.001. Re-operations and re-admission were more frequent after OPEN and length of hospital stay was 2.9 days shorter following LAP (P < 0.001). R1 resections were significantly more common in the OPEN group in the unweighted and weighted analysis with P = 0.004 and P < 0.001 respectively. Therefore, the favourable short-term outcomes following elective LAP versus OPEN resection for colon cancer in routine health care indicate an advantage of laparoscopic surgery.

Evaluation of the learning curve for laparoscopic pyloromyotomy

BACKGROUND

Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons.

METHODS

A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency.

RESULTS

A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases.

CONCLUSION

Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Global survey on the surgical management of patients affected by colorectal cancer with synchronous liver metastases: impact of surgical specialty and geographic region

BACKGROUND

Consensus on the best surgical strategy for the management of synchronous colorectal liver metastases (sCRLM) has not been achieved. This study aimed to assess the attitudes of surgeons involved in the treatment of sCRLM.

METHODS

Surveys designed for colorectal, hepato-pancreato-biliary (HPB), and general surgeons were disseminated through representative societies. Subgroup analyses were performed to compare responses between specialties and continents.

RESULTS

Overall, 270 surgeons (57 colorectal, 100 HPB and 113 general surgeons) responded. Specialist surgeons more frequently utilized minimally invasive surgery (MIS) than general surgeons for colon (94.8% vs. 71.7%, p < 0.001), rectal (91.2% vs. 64.6%, p < 0.001), and liver resections (53% vs. 34.5%, p = 0.005). In patients with an asymptomatic primary, the liver-first two-stage approach was preferred in most respondents' centres (59.3%), while the colorectal-first approach was preferred in Oceania (83.3%) and Asia (63.4%). A substantial proportion of the respondents (72.6%) had personal experience with minimally invasive simultaneous resections, and an expanding role for this procedure was foreseen (92.6%), while more evidence was desired (89.6%). Respondents were more reluctant to combine a hepatectomy with low anterior (76.3%) and abdominoperineal resections (73.3%), compared to right (94.4%) and left hemicolectomies (90.7%). Colorectal surgeons were less inclined to combine right or left hemicolectomies with a major hepatectomy than HPB and general surgeons (right: 22.8% vs. 50% and 44.2%, p = 0.008; left: 14% vs. 34% and 35.4%, p = 0.002, respectively).

CONCLUSION

The clinical practices and viewpoints on the management of sCRLM differ between continents, and between and within surgical specialties. However, there appears to be consensus on a growing role for MIS and a need for evidence-based input.

The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease

BACKGROUND

As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field.

RESULTS

The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve.

CONCLUSIONS

The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

The risk factors for failure and recurrence of LIFT procedure for fistula in ano

Objectives

Fistula in ano (FIA) is a common anorectal problem. There are several techniques that have been used for treatment; however, all of them carry risks of recurrence and incontinence. Ligation intersphincteric fistula tract (LIFT) is a type of treatment with a promising result of preserving the anal sphincter function. This study aimed to evaluate the outcome and risk factor of LIFT failure and to demonstrate the pattern of recurrence. The research funding was supported by Rajavithi Hospital.

Material and Methods

From January 2015 to January 2020, there were 250 cases of fistula in ano operations. A total of 148 patients underwent LIFT operation. The patients' average age was 39.72 ± 10.55 years and the average follow-up period was 111.86 ± 79.73 days. The average time to diagnose the recurrence was 99.12 ± 30.08 days. In addition, average time to perform a surgery after the diganosis was 64.67 ± 25.76 days. The study's analyses used data on age, sex, type of fistula, operative intervention, healing time, reinterventions, and recurrence.

Results

There were 22.97% of recurrence among 148 LIFT patients. Half of the patients who underwent the operation had a preoperative imaging study with MRI or endoanal ultrasonography in the first time due to the complexity of the disease. Factors associated with operation failure were collection, fistula tract size more than 5 millimeters, and the failure of ligating the tract in one attempt.

Conclusion

LIFT procedure is one of the several sphincter saving procedures to treat FIA. Recurrence is related with the complexity of the disease. Most of the recurrence is diseases that are easier to treat, such as performing a re-operation or fistulotomy.

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.

Learning curve of robotic rectal surgery using risk-adjusted cumulative summation: a 5-year institutional experience

PURPOSE

Outline learning phases of robot-assisted laparoscopic surgery for rectal cancer and compare surgical and clinical outcomes between each phase of robot-assisted laparoscopic surgery and the mastery phase of conventional laparoscopic surgery.

METHODS

From 2015 to 2020, 210 patients underwent rectal cancer surgery at Sendai Medical Center. We performed conventional laparoscopic surgery in 110 patients and, laparoscopic surgery in 100 patients. The learning curve was evaluated using the cumulative summation method, risk-adjusted cumulative summation method, and logistic regression analysis.

RESULTS

The risk-adjusted cumulative summation learning curve was divided into three phases: phase 1 (cases 1-48), phase 2 (cases 49-80), and phase 3 (cases 81-100). Duration of hospital stay (13.1 days vs. 18.0 days, respectively; p = 0.016) and surgery (209.1 min vs. 249.5 min, respectively; p = 0.045) were significantly shorter in phase 3 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group. Blood loss volume was significantly lower in phase 1 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group (17.7 ml vs. 79.7 ml, respectively; p = 0.036). The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopic surgery group (p = 0.0131).

CONCLUSIONS

Robot-assisted laparoscopic surgery for rectal cancer was safe and demonstrated better surgical and clinical outcomes, including a shorter hospital stay, less blood loss, and a shorter surgical duration, than conventional laparoscopic surgery. After experience with at least 80 cases, tactile familiarity can be acquired from visual information only (visual haptic feedback).

CLINICAL TRIAL REGISTRATION

UMIN reference no. UMIN000019857.

A new approach: Laparoscopic right hemicolectomy with priority access to small bowel mesentery

Background

For laparoscopic right hemicolectomy, the intermediate approach is commonly employed. However, this approach possesses several disadvantages. In this study, we compare priority access to the small bowel mesentery and the intermediate approach.

Methods

The clinical data of 196 patients admitted to the First Hospital of Chongqing Medical University for laparoscopic right hemicolectomy from January 2019 to January 2022 were retrospectively collected and divided into the small bowel mesenteric priority access and traditional intermediate access groups. The operative time, intraoperative bleeding, number of lymph node dissection, postoperative anal venting time, toleration of solid and liquid intake, and postoperative hospital stay and complications were compared between the two different approaches.

Results

In total, 81 cases of small bowel mesenteric priority access and 115 cases of intermediate approach for right hemi-colonic radical resection were compared. The operative time was 191.98 ± 46.05 and 209.48 ± 46.08 min in the small bowel mesenteric priority access and intermediate access groups, respectively; the difference was statistically significant. There were no significant differences in the intraoperative bleeding and lymph node clearance. However, the scatter plot analysis showed that severe intraoperative bleeding was relatively less frequent in the small mesenteric priority access group, compared with that in the intermediate approach group. Additionally, there were no statistically significant differences in the first exhaust and defecation times, hospital stay after operation, toleration of solid and liquid intake, and postoperative complication between the two groups.

Conclusion

In laparoscopic right hemicolectomy, the small bowel mesenteric priority approach can significantly shorten the operation time compared with the intermediate approach. It can reduce intraoperative bleeding and the operation is simple and safe to perform, making it suitable for less experienced surgeons. Therefore, the small bowel mesenteric priority approach has the potential to be a suitable alternative and deserves further clinical promotion and application.

Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis

BACKGROUND

Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease.

METHODS

All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest.

RESULTS

Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436).

CONCLUSION

In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.

A method for identifying the learning curve for the surgical stabilization of rib fractures

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves.

METHODS

Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data.

RESULTS

Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C.

CONCLUSION

The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Minimally invasive colorectal surgery learning curve

The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.

Environmental sustainability in robotic and laparoscopic surgery: systematic review

BACKGROUND

Minimally invasive surgical (MIS) techniques are considered the gold standard of surgical interventions, but they have a high environmental cost. With global temperatures rising and unmet surgical needs persisting, this review investigates the carbon and material footprint of MIS and summarizes strategies to make MIS greener.

METHODS

The MEDLINE, Embase, and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed surgical setting, waste, carbon footprint, environmental sustainability, and MIS. Two investigators independently performed abstract/full-text reviews. An analysis of disability-adjusted life years (DALYs) averted per ton of carbon dioxide equivalents (CO2e) or waste produced was generated.

RESULTS

From the 2456 abstracts identified, 16 studies were selected reporting on 5203 MIS procedures. Greenhouse gas (GHG) emissions ranged from 6 kg to 814 kg CO2e per case. Carbon footprint hotspots included production of disposables and anaesthetics. The material footprint of MIS ranged from 0.25 kg to 14.3 kg per case. Waste-reduction strategies included repackaging disposables, limiting open and unused instruments, and educational interventions. Robotic procedures result in 43.5 per cent higher GHG emissions, 24 per cent higher waste production, fewer DALYs averted per ton of CO2, and less waste than laparoscopic alternatives.

CONCLUSION

The increased environmental impact of robotic surgery may not sufficiently offset the clinical benefit. Utilizing alternative surgical approaches, reusable equipment, repackaging, surgeon preference cards, and increasing staff awareness on open and unused equipment and desflurane avoidance can reduce GHG emissions and waste.

Audit of laparoscopic surgery for colon cancer in Morocco: A report of the results of a prospective multicentre cohort study

Background

Patients and methods

Results

Conclusions

•

Laparoscopy is the standard technique for colon cancer in rich countries. Little data exists about lower income countries.

•

We evaluated laparoscopy for colon cancer by comparing it to open colon resections in a low-mid income country.

•

We found that Laparoscopy is performed by few surgeons, who apply strict patient selection for laparoscopic cases.

•

Patients in the laparoscopy group also had lower quality resections compared to open surgery.

•

The challenges identified will require more focus on training, certification, centralization, and standardisation of care.

Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer

BACKGROUND

Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection.

METHODS

Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation.

RESULTS

Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively.

CONCLUSIONS

Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.

The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway

BACKGROUND

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.

CONCLUSIONS

The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Change point analysis validation of the learning curve in laparoscopic colorectal surgery: Experience from a non-structured training setting

BACKGROUND

The introduction of minimal invasive principles in colorectal surgery was a major breakthrough, resulting in multiple clinical benefits, at the cost, though, of a notably steep learning process. The development of structured nation-wide training programs led to the easier completion of the learning curve; however, these programs are not yet universally available, thus prohibiting the wider adoption of laparoscopic colorectal surgery.

AIM

To display our experience in the learning curve status of laparoscopic colorectal surgery under a non-structured training setting.

METHODS

We analyzed all laparoscopic colorectal procedures performed in the 2012-2019 period under a non-structured training setting. Cumulative sum analysis and change-point analysis (CPA) were introduced.

RESULTS

Overall, 214 patients were included. In terms of operative time, CPA identified the 110^th case as the first turning point. A plateau was reached after the 145^th case. Subgroup analysis estimated the 58^th for colon and 52^nd case for rectum operations as the respective turning points. A learning curve pattern was confirmed for pathology outcomes, but not in the conversion to open surgery and morbidity endpoints.

CONCLUSION

The learning curves in our setting validate the comparability of the results, despite the absence of National or Surgical Society driven training programs.

Re-laparoscopy to Treat Early Complications After Colorectal Surgery: Is There a Learning Curve?

BACKGROUND

Laparoscopy for treating complications after laparoscopic colorectal surgery (LCS) is still controversial. Moreover, its learning curve has not been evaluated yet. The aim of this study was to analyze whether operative outcomes were influenced by the learning curve of re-laparoscopy.

METHODS

A retrospective analysis of patients undergoing LCS and reoperated by a laparoscopic approach during the period 2000-2019 was performed. A cumulative sum analysis was done to determine the number of operations that must be performed to achieve a stable operative time. Based on this analysis, the cohort was divided in 3 groups. Demographics and operative variables were compared between groups.

RESULTS

From a total of 1911 patients undergoing LCS, 132 (7%) were included. Based on the cumulative sum analysis, the cohort was divided into the first 50 (G1), the following 52 (G2), and the last 30 (G3) patients. Less computed tomography scans were performed in G3 (G1: 72% vs. G2: 63% vs. G3: 43%; P=0.03). There were no differences in the type of operation performed between the groups. The conversion rate (G1: 18% vs. G2: 4% vs. G3: 3%; P=0.02) and the mean operative time (G1: 104 min vs. G2: 80 min vs. G3: 78 min; P=0.003) were higher in G1. Overall morbidity was lower in G3 (G1: 46% vs. G2: 63% vs. G3: 33%; P=0.01). Major morbidity, mortality, and mean length of stay remained similar in all groups.

CONCLUSIONS

A total of 50 laparoscopic reoperations might be needed to achieve an appropriate learning curve with reduced operative time and lower conversion rates. Further research is needed to determine the learning process of re-laparoscopy for treating complications after colorectal surgery.

Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic

Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.

Laparoscopic vs. open resection for colon cancer‑quality of oncologic resection evaluation in a medium volume center

Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.

Supervised training of laparoscopic colorectal cancer resections does not adversely affect short- and long-term outcomes: a Propensity-score-matched cohort study

Background

Supervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself.

Methods

A prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes.

Results

From 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4–82.2) versus 81.9% (74.2–90.4) and 70.0% (60.8–80.6) versus 73.6% (64.9–83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32–1.02, p = 0.057) and 0.87 (0.51–1.48, p = 0.61), respectively (univariate Cox proportional hazard model).

Conclusions

Standardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.

Training on a virtual reality cricothyroidotomy simulator improves skills and transfers to a simulated procedure

Objective

The virtual airway skills trainer (VAST) is a virtual reality simulator for training in cricothyroidotomy (CCT). The goal of the study is to test the effectiveness of training and transfer of skills of the VAST-CCT.

Methods

Two groups, control (no training) and simulation (2 weeks of proficiency-based training), participated in this study. Subjects in the control condition did not receive any training on the task whereas those in the simulation received a proficiency-based training on the task during a period of 2 weeks. Two weeks post-training, both groups performed CCT on the TraumaMan to demonstrate the transfer of skills.

Results

A total of (n=20) subjects participated in the study. The simulation group performed better than the control group at both the post-test (p<0.001) and retention test (p<0.001) on the simulator. The cumulative sum analysis showed that all subjects in the simulation group reached proficiency with acceptable failure rate within the 2 weeks of training. On the transfer test, the simulation group performed better on skin cut (p<0.001), intubation (p<0.001) and total score (p<0.001) than the control group.

Conclusions

The VAST-CCT is effective in training and skills transfer for the CCT procedure.

Level of evidence

Not applicable. Simulator validation study.

Tunnel versus medial approach in laparoscopic radical right hemicolectomy for right colon cancer: a retrospective cohort study

PURPOSE

This study aimed to explore the feasibility and safety of the tunnel approach in laparoscopic radical right hemicolectomy for colon cancer.

METHODS

From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who underwent laparoscopic radical right hemicolectomy at the Affiliated Cancer Hospital of Zhengzhou University were enrolled. The patients were stratified into either a tunnel approach (TA) (n = 56) group or traditional medial approach (MA) (n = 50) group according to the surgical technique performed. The baseline demographics, perioperative outcomes and oncologic outcomes were compared between the two groups.

RESULTS

The baseline characteristics did not differ between groups. The TA group had significantly less blood loss [20.0 (10.0-40.0) vs. 100 (100.0-150.0) ml, p < 0.001] and a shorter operation time [128.4 ± 16.7 vs. 145.6 ± 20.3 min, p < 0.001] than the MA group. The time to first flatus and postoperative hospital stay were similar [3.0 (2.0-4.0) vs. 3.0 (3-4.0) days, p = 0.329; 10.4 ± 2.6 vs. 10.7 ± 3.0 days, p = 0.506] between the two groups. The conversion to laparotomy and complication rates were similar between groups (0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p = 0.603, respectively). No treatment-related deaths occurred in either group. The TA group did not have significantly better survival outcomes than the MA group (p = 0.372).

CONCLUSIONS

The TA seems to allow for more favourable results in terms of blood loss and operative time than the MA, with similar results regarding time to first flatus, hospital stay, postoperative complication rate, conversion rate and oncologic outcomes; moreover, the TA is easier for beginners to master.