Learning Curve Analysis to Determine Operative Requirements for Young Vascular Surgeons Learning Open Abdominal Aortic Aneurysm Repair

Simulation Training in Vascular and Endovascular Surgery: A Nationwide Survey Among Surgeon Educators and Trainees in France

BACKGROUND

Vascular surgical training is evolving towards simulation-based methods to enhance skill development, ensure patient safety, and adapt to changing regulations. This study aims to investigate the utilization of simulation training among vascular surgeons in France, amidst ongoing shifts in teaching approaches and educational reforms.

METHODS

A national survey assessed the experiences and perceptions of vascular surgery professionals regarding simulation training. Participation was open to self-reported health professionals specialized (or specializing) in vascular surgery, including interns or fellows. Participants were recruited through various channels, and data were collected via a questionnaire covering participant characteristics, simulation experiences, and perceptions.

RESULTS

Seventy-six participants, predominantly male (74%) took part in the survey. While 58% reported access to simulation laboratories, only 17% had organized simulation sessions 1-3 times a year, and 5% had sessions more than 10 times annually. High fidelity simulators were available in 57% of institutions, while low fidelity simulators were available in 50%. Regarding funding, 20% received financial assistance for training, predominantly from industry (18%). One-third of the participants experienced 9 or more sessions (34%), lasting between 1 and 2 hours (34%), 30% expressed satisfaction with access to simulation, while 33% were dissatisfied with communication of simulation training opportunities.

CONCLUSIONS

Despite recognizing the benefits of simulation training, its integration into vascular surgery education in France remains incomplete. Challenges such as limited access and communication barriers hinder widespread adoption. Collaborative efforts are needed to ensure uniformity and enhance the effectiveness of simulation training in vascular surgery education.

Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era

Objective

Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes.

Materials and methods

A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward.

Results

A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666).

Conclusion

Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.

Feasibility and learning curve for robotic surgery in a small hospital: A retrospective cohort study

Robotic surgery rates, typified by the use of the da Vinci Surgical System, have increased in recent years. However, robotic surgery is mostly performed in large hospitals and has not been fully implemented in small hospitals. Therefore, we aimed to verify the feasibility of robotic surgery in small hospitals and verify the number of cases in which perioperative preparation for robotic surgery is stable by creating a learning curve in small hospitals. Forty robot-assisted rectal cancer surgeries performed in large and small hospitals by a surgeon with extensive experience in robotic surgery were validated. Draping and docking times were recorded as perioperative preparation times. Unexpected surgical interruptions, intraoperative adverse events, conversion to laparoscopic or open surgery, and postoperative complications were recorded. Cumulative sum analysis was used to derive the learning curve for perioperative preparation time. Draping times were significantly longer in the small hospital group (7 vs 10 minutes, P = .0002), while docking times were not significantly different (12 vs 13 minutes, P = .098). Surgical interruptions, intraoperative adverse events, and conversions were not observed in either group. There were no significant differences in the incidence of severe complications (25% [5/20] vs 5% [1/20], P = .184). In the small hospital group, phase I of the draping learning curve was completed in 4 cases, while phase I of the docking learning curve was completed in 7 cases. Robotic surgery is feasible for small hospitals, and the preoperative preparation time required for robotic surgery stabilizes relatively early.

Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy

BACKGROUND

Although transanal total mesorectal excision (TaTME) is a promising treatment for low rectal cancer, it is considered technically demanding, and the number of cases required to become proficient in TaTME remains unknown. The purpose of this study was to assess the TaTME learning curve based on the total mesorectal excision completion time.

STUDY DESIGN

This retrospective analysis comprised 128 individuals who received TaTME between September 2016 and December 2021. The cumulative sum method was used to generate the learning curve. The duration of the procedure from the beginning to the end of the circumferential rendezvous was used to define the total mesorectal excision completion time.

RESULTS

The learning curve consists of 3 phases: phase I (learning phase: cases 1 to 38), phase II (consolidation phase: cases 39 to 70), and phase III (maturing phase: cases 71 to 128). As the phases varied, both the overall operative time and total mesorectal excision completion time decreased considerably. Through the 3 phases of TaTME, intraoperative adverse events decreased, and in phase III, none occurred. Only 1 instance of local recurrence occurred during phase III, and none occurred during phase I or II.

CONCLUSIONS

After 70 operations, the surgeon could join the mastery phase of TaTME based on the total mesorectal excision completion time. After the mastering phase began, there were no intraoperative negative occurrences. From the beginning, the oncological safety could be guaranteed.

Starting a Vascular Surgery Fellowship at a Rural Healthcare Center

INTRODUCTION

In the United States, there is an anticipated critical shortage of vascular surgeons in the coming decades. The shortage is expected to be particularly pronounced in rural areas. Our institution serves a rural and underserved population in which the incidence and prevalence of cardiovascular disease continues to rise. Our institution maintains a general surgery residency and has all the required Accreditation Council for Graduate Medical Education (ACGME) rotations and educational infrastructure to support a vascular surgery fellowship. This study aims to analyze the vascular caseload at our institution to determine if we and other institutions with similar surgical volumes can support the creation of a 2-year vascular fellowship.

METHODS

A single-site retrospective review of the number and type of vascular cases conducted at our institution between July 2016 and June 2021 was performed. The procedures were grouped into the following ACGME-defined categories: abdominal, cerebrovascular, complex, endovascular aneurysm repair, endovascular diagnostic or therapeutic, and peripheral. The total number and annual average for each category was obtained. Using the annual average, a 2-year estimate was calculated and compared to the ACGME minimum for each category. Our 2-year estimate was then compared to the national average for graduating vascular surgery fellows in order to generate a z-score for each category.

RESULTS

In the specified period, 6100 total surgical procedures were performed by three vascular surgeons at our institution. Two thousand five hundred and seventy-eight of the 6100 procedures met at least one of the ACGME-defined category requirements. Our center greatly exceeded the requirements for each category except for abdominal. This is consistent with trends observed in most centers across the nation, which are seeing a decline in open repairs across all categories, especially in open abdominal repairs. Our center's vascular case volume shows no significant difference the national average in each ACGME category (P ≥ 0.05 for all).

CONCLUSIONS

Despite our center's large vascular caseload and need for more vascular providers, there were not enough open abdominal cases performed to support the training of a vascular fellow. Given the continued decline in open aortic volume across the country, we anticipate that rural centers similar to our own will have difficulty establishing programs to train and recruit vascular surgeons. Flexibility in the abdominal category requirement or creation of open aortic fellowships may be necessary for smaller rural centers to train vascular surgeons and meet the future needs of the specialty.

Can We Still Teach Open Repair of Abdominal Aortic Aneurysm in The Endovascular Era? Single-Center Analysis on The Evolution of Procedural Characteristics Over 15 Years

OBJECTIVE

In many vascular centers an endovascular first policy for the treatment of abdominal aortic aneurysms (AAA) has resulted in endovascular aortic repair (EVAR) outnumbering open aortic repair (OAR). The declining routine in OAR raises the question whether this might influence procedural outcomes and diminish surgical expertise for current and future vascular surgeons. We aimed to analyze OAR outcomes, AAA morphology and procedural details over the past 15 years while an endovascular first approach was successively implemented.

PARTICICPANTS AND DESIGN

All patients operated for (i)ntact infra-/juxtarenal AAA between January 1, 2005 and December 31, 2019 were identified. Outcome parameters were length of stay (hospital/ICU), in-hospital mortality and medical/surgical complications. Operative details were clamping zone, access and graft configuration. AAA anatomy including neck and iliac parameters was analyzed with Endosize©. Logistic regression, uni- and multivariate analysis were applied.

RESULTS

293 patients received elective OAR for iAAA. Baseline characteristics (age, sex, hypertension, smoking, occlusive disease, coronary disease, hyperlipidemia, diabetes, renal insufficiency and obesity) did not change over time. The number of OAR dropped significantly (-0.5 cases/year p = 0.02). The procedure time (2005-2007: 192.2 ± 87.5min to 2017-2019: 235.6 ± 88.2min; p = 0.0001) and the length of stay (2005-2007: 12.0 ± 7.9 to 2017-2019: 17.0 ± 23.1; p = 0.03) increased significantly, whereas the in-hospital mortality, length of ICU stay and complication rates didn't, nor did AAA anatomy. Upon multivariate analysis, annual number of OAR and any additional anastomosis significantly influenced procedure time, trainee involvement, for example, did not. Hospital length-of-stay depended on patient age (p = 0.002), complication rates (p < 0.0001) and procedure time (p = 0.006).

CONCLUSION

Mortality and complication rates for OAR have remained low and constant. With the increase of EVAR, the absolute number of OARs has decreased significantly. However, the total procedure time has increased and depends significantly on the annual number of OARs in total and per surgeon. This might influence outcome parameters and should be implanted in future surgical education.

Tailor-Made Tapering Grafts for Large-Neck Aorta

Patients having a large aortic neck poses a challenge in abdominal aortic aneurysm surgery both in endovascular and open aneurysm repair, sometimes necessitating paravisceral or thoracoabdominal aneurysm repair which carries considerable perioperative risk. Here, we describe techniques of using a tailor-made tapering graft in open surgery that can be adjusted for large neck morphology. This technique helps avoid discrepancies between the proximal aorta and graft, and postoperative acute kidney injury by clamping at lower levels. The conscientious use of this technique in selected patients realizes satisfactory outcomes both in the short term and midterm in the demanding anatomy of large aortic necks.

Association between hospital volume and failure-to-rescue for open repairs of juxtarenal aneurysms

BACKGROUND

A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals.

METHODS

Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue.

RESULTS

We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P < .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02).

CONCLUSIONS

Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.

Learning Curves and Competences of Vascular Trainees Performing Open Aortic Repair in a Simulation-Based Environment

BACKGROUND

The aim of this study was to analyze learning curves and competency gains of novice vascular trainees when performing open aortic repair in a simulation-based environment.

METHODS

This was a prospective study of 16 vascular trainees performing infrarenal open aortic repair on an inanimate abdominal aortic aneurysm simulator with pulsatile pressure and flow. Each participant performed 4 procedures as a primary surgeon while getting structured feedback by a supervising experienced vascular surgeon. All sessions were video recorded and were anonymously and independently assessed by 3 rater-trained experts on an online platform using the newly validated open abdominal aortic aneurysm repair of technical expertise assessment tool. All supervisor interferences and procedure time was noted.

RESULTS

Reliability between raters was excellent (intraclass correlation coefficient = 0.92). Participants' mean scores almost doubled during the course between the first (13.4, 95% confidence interval [CI], 6.8-20) and fourth session (29.8, 95% CI, 26.3-33.3) with a mean difference of 14.6 (P < 0.001). Supervisor interference also decreased significantly from mean 3.0 (95% CI, 1.5-3.6) in the first to 0.7 (95% CI, 0.4-1.0) in the fourth session (P = 0.004). Procedure time decreased with a mean of 24 minutes: from 81 min (95% CI, 71.8-90.3) to 57 min (95% CI, 51.1-63.2, P < 0.001). There was a significant negative correlation between procedure time and the Open Abdominal Aortic Aneurysm Repair of Technical Expertise score (Pearson's r = -0.72, P < 0.01). Only half of the participants passed the pass/fail score of 27.7 points during the course.

CONCLUSIONS

Novice vascular trainees achieve skills and competencies in open aortic repair in a simulated setting with dedicated supervision and feedback and can become ready for supervised surgery on real patients. Learning rates are individual, and it is important to construct training programs with emphasis on proficiency and not merely attending a course.