European Association For Endoscopic Surgery Research Articles

Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice.

Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery. A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics. We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery. This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms

BackgroundThe healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world.MethodsThe Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future.ResultsSeveral key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders.DiscussionThis position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Detection and Real-Time Surgical Assessment of Colorectal Liver Metastases Using Near-Infrared Fluorescence Imaging during Laparoscopic and Robotic-Assisted Resections.

The European Association of Endoscopic Surgery (EAES) recommends, with strong evidence, the use of indocyanine green (ICG) fluorescence imaging combined with intraoperative ultrasound (IOUS) to improve identification of superficial liver tumors. This study reports the use of ICG for the detection of colorectal liver metastases (CRLMs) during minimally invasive liver resection. A single-center consecutive series of minimally invasive (laparoscopic and robotic) hepatic resections for CRLMs was prospectively evaluated (April 2019 and October 2023). A total of 25 patients were enrolled-11 undergoing laparoscopic and 14 undergoing robotic procedures. The median age was 65 (range 50-85) years. Fifty CRLMs were detected: twenty superficial, eight exophytic, seven shallow (<8 mm from the hepatic surface), and fifteen deep (>10 mm from the hepatic surface) lesions. The detection rates of CRLMs through preoperative imaging, laparoscopic ultrasound (LUS), ICG fluorescence, and combined modalities (ICG and LUS) were 88%, 90%, 68%, and 100%, respectively. ICG fluorescence staining allowed us to detect five small additional superficial lesions (not identified with other preoperative/intraoperative techniques). However, two lesions were false positive fluorescence accumulations. All rim fluorescence pattern lesions were CRLMs. ICG fluorescence was used as a real-time guide to assess surgical margins during parenchymal-sparing liver resections. All patients with integrity of the fluorescent rim around the CRLM displayed a radical resection during histopathological analysis. Four patients (8%) with a protruding rim or residual rim patterns had positive resection margins. ICG fluorescence imaging can be integrated with other conventional intraoperative imaging techniques to optimize intraoperative staging. Rim fluorescence proved to be a valid indicator of the resection margins: by removing the entire fluorescent area, a tumor-negative resection (R0) is achieved.

Perceived comfort and tool usability during robot-assisted and traditional laparoscopic surgery: a survey study

It is known that over half of previously surveyed surgeons performing Robot-Assisted Laparoscopic Surgery (RALS) and three-quarters of those performing Traditional Laparoscopic Surgery (TLS) experience intraoperative pain. This survey study aimed to expand upon the ongoing impact of that pain as well as perceived tool usability associated with TLS and RALS, for which considerably less documentation exists. A survey regarding the presence and impact, either immediate or ongoing, of intraoperative pain and Likert scale questions regarding tool usability was administered to TLS and RALS surgeons on the European Association for Endoscopic Surgery (EAES) mailing list. Prevalence statistics as well as trends based on biological sex and glove size were obtained from the 323 responses. Most respondents were right-handed European males (83−88%) with a medium glove size (55.8%). Moderate or severe shoulder symptoms were experienced by one-third of TLS surgeons. Twenty-one percent of RALS surgeons experienced neck symptoms that impacted their concentration. Small-handed surgeons experienced wrist symptoms significantly more frequently than large-handed surgeons, regardless of modality. RALS was associated with a significantly more optimal back and wrist posture compared to TLS. TLS surgeons reported increased ease with applying and moderating force while operating. These results suggest that intraoperative pain may be severe enough in many cases to interfere with surgeon concentration, negatively impacting patient care. Continuing to understand the relationship between tool usability and comfort is crucial in guaranteeing the health and well-being of both surgeons and patients.

The burden of the knowledge-to-action gap in acute appendicitis

BackgroundThe burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.MethodsData were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.ResultsFrom 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%).Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.ConclusionsWe confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.

The relevance of reducing Veress needle overshooting

Safe insertion of the Veress needle during laparoscopy relies on the surgeons’ technical skills in order to stop needle insertion just in time to prevent overshooting in the underlying organs. To reduce this risk, a wide variety of Veress needle systems were developed with safety mechanisms that limit the insertion speed, insertion depth or decouple the driving force generated by the surgeon’s hand on the needle. The aim of this study is to evaluate current surgeons’ perceptions related to the use of Veress needles and to investigate the relevance of preventing overshooting of Veress needles among members of the European Association of Endoscopic Surgery (EAES). An online survey was distributed by the EAES Executive Office to all active members. The survey consisted of demographic data and 14 questions regarding the use of the Veress needle, the training conducted prior to usage, and the need for any improvement. A total of 365 members residing in 58 different countries responded the survey. Of the responding surgeons, 36% prefer the open method for patients with normal body mass index (BMI), and 22% for patients with high BMI. Of the surgeons using Veress needle, 68% indicated that the reduction of overshoot is beneficial in normal BMI patients, whereas 78% indicated that this is beneficial in high BMI patients. On average, the members using the Veress needle had used it for 1448 (SD 3031) times and felt comfortable on using it after 22,9 (SD 78,9) times. The average years of experience was 17,6 (SD 11,1) and the surgeons think that a maximum overshoot of 9.4 (SD 5.5) mm is acceptable before they can safely use the Veress needle. This survey indicates that despite the risks, Veress needles are still being used by the majority of the laparoscopic surgeons who responded. In addition, the surgeons responded that they were interested in using a Veress needle with an extra safety mechanism if it limits the risk of overshooting into the underlying structures.

51 Evaluating the Impact of International Surgical Society Research Grant Funding

Abstract Introduction Research impact is defined as the influence of research beyond academia. The European Association of Endoscopic Surgery (EAES) supports research through financial and training support. With the current project we aim to define and objectively measure the impact of research supported by one of the biggest surgical societies in Europe. Methods &amp; Procedures A Steering Committee finalised the questionnaire through a Delphi process. This was disseminated to all previous EAES Research Grant recipients since 2011. Results were used to generate open ended questions for semi-structured interviews. Thematic analysis was performed. Results The questionnaire response rate was 22/30(73%). The median number of presentations was 2.5, highest number of citations/year was 19. Seven respondents participated on guideline committees, while 15 were involved in further research, including six multicentre trials. Three studies instigated changes in clinical policies. Two intellectual property designs were produced. Eight recipients received further funding. Experts rated a median positive impact of 5/7 on their career progression, while supervised non-experts rated 6/7. The framework from interview thematic analysis included the following topics: (i)benefits of EAES involvement (ii)career progression (academic-clinical) (iii)impact on skills (iv)network impact (v) overall impact (vi)EAES project support (vii)project challenges (viii)EAES project results (ix)study design suitability, and (x)EAES future scope. Conclusions The impact of research funding by EAES was significant; both academically and outside academia. The semi-structured interviews identified the facilitators and barriers to project progression and impact.

The impact of the European Association of Endoscopic Surgery research grant scheme-a mixed qualitative quantitative methodology study protocol.

The European Association of Endoscopic Surgery (EAES) is a surgical society who promotes the development and expansion of minimally invasive surgery to surgeons and surgical trainees. It does so through its activities in education, training, and research. The EAES research committee aims to promote the highest quality clinical research in endoscopic and minimally invasive surgery. They have provided grant funding since 2009 in education, surgery, and basic science. Despite the success and longevity of the scheme, the academic and non-academic impact of the research funding scheme has not been evaluated. The primary aim of this project is to assess the short, long term academic and real world impact of the EAES funding scheme. The secondary aims are to identify barriers and facilitators for achieving good impact. This will be a mixed qualitative and quantitative study. Semi-structured interviews will be performed with previous grant recipients. The questions for the interviews will be selected after a consensus is achieved amongst the members of the steering committee of this project. The responses will be transcribed and thematic analysis will be applied. The results of the thematic analysis will be used to populate a questionnaire which will be disseminated to grant recipients. This study is kindly funded by the EAES. The first question this project is expected to answer is whether the EAES research funding scheme had a significant positive impact on research output, career progression but also non-academic output such as change in clinical guidelines, healthcare quality and cost-effectiveness improvement. This project however is also expected to identify facilitators and barriers to successful completion of projects and to achieving high impact. This will inform EAES and the rest of the surgical and academic communities as to how clinicians would like to be supported when conducting research. There should also be a positive and decisive change towards removing factors that hinder the timely and successful completion of projects.

European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery

BackgroundIn recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.MethodsAn expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.ResultsA total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.ConclusionsOverall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

OGBN P11 Gallbladder polyps: an audit of management in an NHS trust

Abstract Background Gallbladder polyps are elevations in the gallbladder wall which project into the lumen. These can be either true polyps or “pseudopolyps” (such as cholesterol or inflammatory deposits or focal adenomyomatosis). Polyp prevalence has been estimated as high as 9.5% in some studies, of which 70% may be pseudopolyps. A small minority of true polyps may display malignant potential. Gallbladder malignancy is aggressive, especially when diagnosed at later stages of disease with poor treatment options and survival outcomes. However, Stage I disease has excellent 5 year survival rates, nearing 100%. Early identification of patients at risk of gallbladder malignancy is highly important and may detect curable disease. Joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery (EAES), International Society of Digestive Surgery – European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE) have outlined best practice in regards to management of gallbladder polyps. This audit compared the current practice in a NHS healthcare trust against these guidelines in order to develop trust-wide consensus and guidelines for future management. Methods A PACS based radiology search was conducted, identifying all patients who underwent an ultrasound between 10th December 2020 and 10th December 2021, whose imaging report used the term “gallbladder polyp(s)” within a hospital trust. Patients without a diagnosis of gallbladder polyp were excluded from the audit. Historical patient records were accessed via the trust-based online patient database (Clinical Portal). Data were collected and analysed using Microsoft excel. Patient management was compared against the following ESGAR/EAES/EFISDS/ESGE guidelines: Results A total of fifty six patients fit the inclusion criteria, with an age range of 8 to 96 years. The majority were female (63%). Polyp size ranged from &amp;lt;2mm to 14mm. Patients were predominantly managed by Upper GI surgery, gastroenterology and general practice with the Radiology department performing and reporting ultrasounds and advising management or follow up. Results showed that 86% of patients were appropriately offered surgery for polyps ≥ 10mm. However, 40% of patients with polyps &amp;gt;5mm with risk factors, were not offered cholecystectomy and 44% of those without risk factors were not offered appropriate follow up. The majority of patients with polyps ≤ 5mm with risk factors were not offered ultrasound surveillance. All patients without risk factors with polyps ≤ 5mm were appropriately managed. Conclusions Key findings suggest discrepancies in the management of patients with gallbladder polyps in a NHS Trust. In particular, patients with risk factors and polyps between 6–9mm were not always identified as requiring operative management. Likewise, over half of those without risk factors were not offered surveillance imaging. Poor management and lack of follow up may put patients at risk. The results of this audit demonstrate the need for unified local or national guidelines concerning management of gallbladder polyps and consensus across multiple disciplines.

Surgical education in the post-COVID era: an EAES DELPHI-study

BackgroundsTo date, it is unclear what the educational response to the restrictions on minimally invasive surgery imposed by the COVID-19 pandemic have been, and how MIS-surgeons see the post-pandemic future of surgical education. Using a modified Delphi-methodology, this study aims to assess the effects of COVID on MIS-training and to develop a consensus on the educational response to the pandemic.MethodsA three-part Delphi study was performed among the membership of the European Association of Endoscopic Surgery (EAES). The first survey aimed to survey participants on the educational response in four educational components: training in the operating room (OR), wet lab and dry lab training, assessment and accreditation, and use of digital resources. The second and third survey aimed to formulate and achieve consensus on statements on, and resources in, response to the pandemic and in post-pandemic MIS surgery.ResultsOver 247 EAES members participated in the three rounds of this Delphi survey. MIS-training decreased by 35.6–55.6%, alternatives were introduced in 14.7–32.2% of respondents, and these alternatives compensated for 32.2–43.2% of missed training. OR-training and assessments were most often affected due to the cancellation of elective cases (80.7%, and 73.8% affected, respectively). Consensus was achieved on 13 statements. Although digital resources were deemed valuable alternatives for OR-training and skills assessments, face-to-face resources were preferred. Videos and hands-on training–wet labs, dry labs, and virtual reality (VR) simulation–were the best appreciated resources.ConclusionsCOVID-19 has severely affected surgical training opportunities for minimally invasive surgery. Face-to-face training remains the preferred training method, although digital and remote training resources are believed to be valuable additions to the training palette. Organizations such as the EAES are encouraged to support surgical educators in implementing these resources. Insights from this Delphi can guide (inter)national governing training bodies and hospitals in shaping surgical resident curricula in post pandemic times.

IATROGENIC INJURIES OF SUBVESICAL BILE DUCT - CASE REPORT AND LITERATURE REVIEW

With the rise of laparoscopic cholecystectomy as the gold standard for treating gallbladder calculi andpolyps, subvesical bile ducts are gaining increased clinical importance. With the introduction of electrocautery insurgery, a large part of these tubular structures, although with interrupted continuity, do not show extravasation ofbile content postoperatively. Decreased bile production during general anesthesia and increased intraperitonealpressure also make diagnosis of injuries difficult. Surgeons who frequently operate in the right upper quadrant haveto understand the anatomy of the biliary tree and its tendency for structural variation. The work of laparoscopicsurgeons should be conceptualized around three main goals: to enable safe identification of key anatomicalstructures, usually by providing a critical point of safety (Critical View of Safety), to make a decision at the rightmoment not to proceed with laparoscopic surgery when working conditions become too dangerous and there is nopossibility of identification of structures and to end the laparoscopic surgery with subtotal cholecystectomy whenidentification of structures is impossible. Controversy among authors on the naming of the various subvesicalstructures causes confusion in their identification and description. In order to overcome these challenges, there was aneed to establish classification systems for post-cholecystectomy lesions of the biliary tract. But due to theindividual shortcomings of all these systems, in June 2011, during the 19th meeting of the European Association forEndoscopic Surgery in Turin, Italy, a conference was held to reach a consensus to establish a uniform classificationof iatrogenic bile duct injuries that will have two primary goals: first, to take into account changes in the type ofinjuries with the introduction of laparoscopic cholecystectomy, and second, to combine all existing classificationsystems and integrate them into one, universally accepted classification system. As part of the new inclusiveclassification system for iatrogenic injuries of the biliary ducts, the following systems are considered: Bismuth,Strasberg et al., McMahon et al., AMA, Neuhaus et al., Csendes et al., Steward et al., Hanover, Lau and Lai ,Siewert et al., Cannon et al., Kapoor., Sandha et al.. In the new system a total of fifteen classifications areincorporated using semantic connotations and grouped into three categories that will allow easy memorization bysurgeons. A (anatomy) for anatomy, To (time of) for time/moment of observation and M (mechanism) for themechanism of occurrence of the injury. By enabling a more precise classification of each of the injuries, the surgicalcommunity will have the opportunity to develop recommendations for prevention, treatment and prognosis for theiroutcome.

ESCP President's report.

ESCP President's report.

EP-473 Laparoscopy versus Laparotomy for Abdominal Trauma: a Case of Iatrogenic Haemoperitoneum in a Haemodynamically Unstable patient

Abstract Introduction Laparoscopy is the gold-standard approach to elective abdominal surgery. Nevertheless, its application to abdominal trauma, including the treatment of haemoperitoneum, has been historically challenged by links to missed injuries. The European Association for Endoscopic Surgery does not clearly recommend therapeutic laparoscopy in trauma, despite the recognised potential benefits, in light of the scarcity and poor standardisation of available evidence. Case description A 68-year old male, presented with worsening shortness of breath and ascites. He was in type-2 respiratory and renal failure on a background of decompensated heart failure. He was admitted to the ITU for circulatory and ventilatory support and underwent ascitic drainage, removed on day 2. On day 3, the patient became peritonitic, exhibited a haemoglobin drop and went into class 2 haemorrhagic shock. A CT-abdomen showed moderate haemorrhagic ascites. An emergency laparoscopy was undertaken, which revealed active bleeding from the left lower abdominal wall. Haemostasis was achieved with ligation and electrocautery of the deep inferior epigastric perforators. Post-operatively, the patient showed a sustained clinical improvement. On day 4 he was stepped down to the ward and on day 10 discharged without further complications. Discussion Therapeutic laparoscopy is efficacious and safe in selected cases of intra-abdominal trauma, as revealed by emerging literature. The haemodynamic stability of the patient is not always a pre-requisite, and the patient's preoperative comorbidities can be key in deciding in favour of laparoscopy. We underline the following important conditions for success: an experienced surgeon, a systematic approach, suitable equipment and short time to surgery.

Abstracts from the 29th International Congress of the European Association for Endoscopic Surgery (EAES), Barcelona, Spain, 24–27 November 2021

Abstracts from the 29th International Congress of the European Association for Endoscopic Surgery (EAES), Barcelona, Spain, 24–27 November 2021

AGREE-S: AGREE II extension for surgical interventions: appraisal instrument.

The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was developed to evaluate the quality of clinical practice guidelines. Evidence suggests that development, reporting, and appraisal of guidelines on surgical interventions may be better informed by modification of the instrument. We aimed to develop an AGREE II extension specifically designed for appraisal of guidelines of surgical interventions. In a three-part project funded by the United European Gastroenterology and the European Association for Endoscopic Surgery, (i) we identified factors that were associated with higher quality of surgical guidelines, (ii) we statistically calibrated the AGREE II instrument in the context of surgical guidelines using correlation, reliability, and factor analysis, and (iii) we undertook a Delphi consensus process of stakeholders to inform the development of an AGREE II extension instrument for surgical interventions. Several features were prioritized by stakeholders as of particular importance for guidelines of surgical interventions, including development of a guideline protocol, consideration of practice variability and surgical expertise in different settings, and specification of infrastructures required to implement the recommendations. The AGREE-S-AGREE II extension instrument for surgical interventions has 25 items, compared to the 23 items of the original AGREE II instrument, organized into the following 6 domains: Scope and purpose, Stakeholders, Evidence synthesis, Development of recommendations, Editorial independence, and Implementation and update. As the original instrument, it concludes with an overall appraisal of the quality of the guideline and a judgement on whether the guideline is recommended for use. Several items were amended and rearranged among domains, and an item was deleted. The Rigor of Development domain of the original AGREE II was divided into Evidence Synthesis and Development of Recommendations. Items of the AGREE II domain Clarity of Presentation were incorporated in the new domain Development of Recommendations. Three new items were introduced, addressing the development of a guideline protocol, support by a guideline methodologist, and consideration of surgical experience/expertise. The AGREE-S appraisal instrument has been developed to be used for assessment of the methodological and reporting quality of guidelines on surgical interventions.

Safe implementation of hand held steerable laparoscopic instruments: a survey among EAES surgeons

The complexity of handheld steerable laparoscopic instruments (SLI) may impair the learning curve compared to conventional instruments when first utilized. This study aimed to provide the current state of interest in the use of SLI, the current use of these in daily practice and the type of training which is conducted before using SLI in the operating room (OR) on real patients. An online survey was distributed by European Association of Endoscopic Surgery (EAES) Executive Office to all active members, between January 4th and February 3rd, 2020. The survey consisted of 14 questions regarding the usage and training of steerable laparoscopic instruments. A total of 83 members responded, coming from 33 different countries. Twenty three percent of the respondents using SLI, were using the instruments routinely and of these 21% had not received any formal training in advance of using the instruments in real patients. Of all responding EAES members, 41% considered the instruments to potentially compromise patient safety due to their complexity, learning curve and the inexperience of the surgeons. The respondents reported the three most important aspects of a possible steerable laparoscopic instruments training curriculum to be: hands-on training, safe tissue handling and suturing practice. Finally, a major part of the respondents consider force/pressure feedback data to be of significant importance for implementation of training and assessment of safe laparoscopic and robotic surgery. Training and assessment of skills regarding safe implementation of steerable laparoscopic instruments is lacking. The respondents stressed the need for specific hands-on training during which feedback and assessment of skills should be guaranteed before operating on real patients.

Surgical endoscopy education research: how are we doing?

Surgical endoscopy (SE), the official journal of the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery, is an important source of new evidence pertaining to surgical education in the field. However, qualitative deficiencies in medical education research have prompted medical education leaders to advocate for increased methodological rigor. The purpose of this study is to review the quality of education-focused research published through SE. A PubMed search examining all SE articles categorized as education-related research from 2010 to 2019 was conducted; studies not meeting inclusion criteria were excluded. Remaining publications were independently reviewed, classified, and scored by 7 raters using the medical education research study quality instrument (MERSQI). Intraclass correlation was calculated and data were examined with descriptive statistics. A total of 227 studies met inclusion criteria. There was no significant difference in number of publications by year (average 25.88 [SD 5.6]); 60% were conducted outside of the United States, and 47% (n = 106) were funded. The average MERSQI was 12.5 (SD 2). Most studies used two-group non-random (42%, n = 96) or post/cross-sectional designs (29%, n = 65). Thirty-six (16%) were randomized controlled trials. Multi-institutional studies comprised 24% (n = 54). Of the manuscripts, 96% (n = 217) reported at least one measure of validity evidence and 28% (n = 67) described three levels of validity evidence. Studies primarily reported changes in skills or knowledge (45%, n = 103) or satisfaction or general facts (44%, n = 99), while patient-related outcomes encompassed 3% (n = 6) of studies. ICC between raters was 0.93 (CI 0.90-0.93, p < 0.001). Based on publications to date, this journal's peer review process appears to facilitate the dissemination of education-related studies of moderate to good quality. However, there were uncovered deficits, ranging from validity evidence to study designs and level of outcomes. This journal's breadth of viewership offers a potential venue to advance education-related research.

Giant spleen as a surgical challenge: Case report and literature review

Introduction. According to the guidelines of the European Association of Endoscopic Surgery, any case where the maximum craniocaudal splenic diameter exceeds 20 cm is considered massive splenomegaly. In addition to metabolic, hematological, and hemodynamic problems, enlarged spleen may cause mechanical difficulties due to the pressure to surrounding organs and vascular structures. The aim of this paper is to present the surgical challenges and technique applied in massive splenomegaly, in a patient who had neglected the importance of regular medical checkups. Case outline. We present a 62-year-old male patient who was admitted to hospital for treatment of previously clinically and radiologically verified splenomegaly but who neglected the importance of regular checkups and medical treatment. Splenectomy was performed with a splenic specimen 38 cm in its maximal diameter. Conclusion. Taking into consideration all the possible benefits and possible complications of surgical treatment, including the quality of life of splenectomized patients, comprehensive preoperative assessment should be made, and surgical treatment selectively applied.

A Concern for Intraoperative Distractions and Interference: An Observational Study Identifying, Measuring, and Quantifying Both within the Operating Theatre.

Background Modern surgical research has broadened to include an interest into the investigation of surgical workflow. Rigorous analysis of the surgical process has a particular focus on distractions. Operating theatres are inherently full of distractions, many not pertinent to the surgical process. Distractions have the potential to increase surgeon stress, operative time, and complications. Our study aims to objectively identify, classify, and quantify distractions during the surgical process. Methods 46 general surgical procedures were observed within a tertiary Irish hospital between June 2019 and October 2019. An established observational tool was used to apply a structured observation to all operations. Additionally, a nine-point ordinal behaviourally anchor scoring scale was used to assign an interference level to each distraction. Results The total operative observation time was 4605 minutes (mean = 100.11 minutes, std. deviation: 45.6 minutes). Overall, 855 intraoperative distractions were coded. On average, 18.58 distractions were coded per operation (std. deviation: 6.649; range: 5–34), with 11.14 distractions occurring per hour. Entering/exiting (n = 380, 42.88%) and case irrelevant communication (n = 251, 28.32%) occurred most frequently. Disruption rate was highest within the first (n = 275, 32%) and fourth operative quartiles (n = 342, 41%). Highest interference rates were observed from equipment issue and procedural interruptions. Anaesthetists initiated CIC more frequently (2.72 per operation), compared to nurses (1.57) and surgeons (1.17). Conclusion Our results confirm that distractions are prevalent within the operating theatre. Distractions contribute to significant interferences of surgical workflow. Steps can be taken to reduce overall prevalence and interference level by drawing upon a systems-based perspective. However, due to the ubiquitous nature of distractions, surgeons may need to develop skills to help them resume interrupted primary tasks so as to negate the effects distraction has on surgical outcomes. Data for the above have been presented as conference abstract in 28th International Congress of the European Association for Endoscopic Surgery (EAES) Virtual Congress, 23–26 June 2020.