Expert Laparoscopic Surgeons Research Articles

Surgical quality assessment for the prospective study of oncologic outcomes after laparoscopic modified complete mesocolic excision for nonmetastatic right colon cancer (PIONEER study).

The modified complete mesocolic excision (mCME) procedure for right-sided colon cancer is a tailored approach based on the original complete mesocolic excision (CME) methodology. Limited studies evaluated the safety and feasibility of laparoscopic mCME using objective surgical quality assessments in patients with right colon cancer. The objectives of the PIONEER study were to evaluate oncologic outcomes after laparoscopic mCME and to identify optimal clinically relevant endpoints and values for standardizing laparoscopic right colon cancer surgery based on short-term outcomes of procedures performed by expert laparoscopic surgeons. This is an ongoing prospective, multi-institutional, single-arm study conducted at five tertiary colorectal cancer centers in South Korea. Study registrants included 250 patients scheduled for laparoscopic mCME with right-sided colon adenocarcinoma (from the appendix to the proximal half of the transverse colon). The primary endpoint was 3-year disease-free survival. Secondary outcomes included 3-year overall survival, incidence of morbidity in the first 4 weeks postoperatively, completeness of mCME, central radicality, and distribution of metastatic lymph nodes. Survival data will be available after the final follow-up date (June 2024). The postoperative complication rate was 12.9%, with a major complication rate of 2.7%. In 87% of patients, central radicality was achieved with dissection at or beyond the level of complete exposure of the superior mesenteric vein. Mesocolic plane resection with an intact mesocolon was achieved in 75.9% of patients, as assessed through photographs. Metastatic lymph node distribution varied by tumor location and extent. Seven optimal clinically relevant endpoints and values were identified based on the analysis of complications in low-risk patients. Laparoscopic mCME for right-sided colon cancer produced favorable short-term postoperative outcomes. The identified optimal clinically relevant endpoints and values can serve as a reference for evaluating surgical performance of this procedure.

Global assessment of surgical skills (GASS): validation of a new instrument to measure global technical safety in surgical procedures.

Broad implementation of the American Board of Surgery's entrustable professional activities initiative will require assessment instruments that are reliable and easy to use. Existing assessment instruments of general laparoscopic surgical skills have limited reliability, efficiency, and validity across the spectrum of formative (low-stakes) and summative (high-stakes) assessments. A novel six-item global assessment of surgical skills (GASS) instrument was developed and evaluated with a focus upon safe versus unsafe surgical practice scoring rubric. The GASS was developed by iterative engagement with expert laparoscopic surgeons and includes six items (economy of motion, tissue handling, appreciating operative anatomy, bimanual dexterity, achievement of hemostasis, overall performance) with a uniform three-point scoring rubric ("poor-unsafe", "adequate-safe", "good-safe"). To test inter-rater reliability, a cross-sectional study of four bariatric surgeons with experience ranging from 4 to 28years applied the GASS and the global operative assessment of laparoscopic skills (GOALS) to 30 consecutive Roux-en-Y gastric bypass procedure operative videos. Inter-rater reliability was assessed for a simplified dichotomous "safe" versus "unsafe" scoring rubric using Gwet's AC2. The GASS inter-rater reliability was very high across all six domains (0.88-1.00). The GASS performed comparably to the GOALS inter-rater reliability scores (0.96-1.00). The economy of motion and bimanual dexterity items had the highest percentage of unsafe ratings (9.2% and 5.8%, respectively). The GASS, a novel six-item instrument of general laparoscopic surgical skills, was designed with a simple scoring rubric (poor-safe, adequate-safe, good-safe) to minimize rater burden and focus feedback to trainees and promotion evaluations on safe surgical performance. Initial evaluation of the GASS is promising, demonstrating high inter-rater reliability. Future research will seek to assess the GASS against a broader spectrum of laparoscopic procedures.

Long-term oncological outcome of reduced-port laparoscopic surgery (single-incision plus one port) as a technical option for rectal cancer.

The purpose of this study was to clarify the oncological safety of reduced-port laparoscopic surgery (single-incision plus one port) (RPS) for patients with rectal cancer. The clinicopathological data of 63 selected patients with clinical Stage I-III (T1-3 and N0-2) rectal cancer who underwent RPS of radical anterior resection between 2012 and 2017 were retrospectively analyzed. The median distance of tumor from anal verge was 11 cm. Ordinarily, a multiport platform with three channels was placed in the 3-cm umbilical incision, and another 5- or 12-mm port was placed in the right lower abdomen. The median operative time, amount of intraoperative bleeding, number of harvested lymph nodes, and length of distal margin were 272 min, 10 mL, 22 nodes, and 4.0 cm, respectively, and there was one (2%) patient with involvement of the radial margin. There were eight patients (13%) who required additional ports, and one patient (2%) who converted to open surgery. Intra- and postoperative complications occurred in one (2%) and 12 patients (19%), respectively. The median length of postoperative hospital stay was 8 days. The median follow-up period was 79 months, and incisional hernia was observed in 3 (5%) patients at the platform site not the port site, and cancer recurrence occurred in four patients (6%). The 5-year relapse-free and overall survival rates were 100% and 100% in the patients with pathological Stage I disease, 94% and 100% in the patients with pathological Stage II disease, and 83% and 89% in the patients with pathological Stage III disease, respectively. RPS in the selected patients with rectal cancer, performed by an expert laparoscopic surgeon, may be technically safe and oncologically acceptable as well as multiport laparoscopic surgery.

Does 3D laparoscopic video technology affect long-term survival in right hemicolectomy for cancer compared to standard 2D? A propensity score study.

There are few studies focused on the short-term results of laparoscopic right hemicolectomy performed with 2D (two-dimension) or 3D (three-dimension) video technology and none on the oncologic effects. The aim of the study was to assess the long-term results of laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis using 3D or 2D video in patients with right colon cancer with at least three years of oncologic follow-up. Data from patients undergoing laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis for cancer in an 11-year period (June 2008-June 2019) and ≥ 3years of follow-up were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. 111 patients were included in the study: 56 (50.5%) in the 3D group and 55 (49.5%) in the 2D group. Tumor stage and number of lymph nodes harvested were similar. Overall and disease-free survival were not different in the two groups. Local recurrence occurred in none of the patients, and distant metachronous metastases were similar in the two groups. A propensity score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach. Laparoscopic 3D technology allows similar oncological results as 2D vision in LRH with intracorporeal anastomosis. Larger prospective randomized studies might confirm these results in the long-term follow-up.

A novel model for hands-on laparoscopic pelvic surgery training on Genelyn-embalmed body: an initial feasibility study.

The human donor body provides a well-accepted ex vivo model for laparoscopic surgical training. Unembalmed, or fresh-frozen, bodies comprise high-fidelity models. However, their short life span and high cost relatively limit the hands-on training benefits. In contrast, soft embalmed body of donors has a relatively longer usability without compromising tissue flexibility. This study reports the initial experience of the utility and feasibility of human donor Genelyn-embalmed body as a novel soft-embalmed cadaveric model for laparoscopic surgical training. An expert laparoscopic surgeon, who organised many fresh-frozen body donor courses, performed deep laparoscopic pelvic dissection and laparoscopic surgical tasks including suturing and electrosurgery on a single Genelyn-embalmed body. The three sessions were performed over a course of 3weeks. The body was fully embalmed using the Genelyn technique. The technique consisted of a single-point closed arterial perfusion of embalming solution via the carotid artery with no further exposure to or immersion in embalming fluids thereafter. The donor's Genelyn-embalmed body provided a feasible model for laparoscopic surgical training. Initial experience shows evidence of this model being feasible and realistic. There was reproducibility of these qualities across a minimum of 3weeks in this single-donor study. Initial experience shows that donor's Genelyn-embalmed body provides a novel model for laparoscopic surgical training, which possesses fidelity and is feasible for laparoscopic training. While further studies are needed to validate these findings, this technical note provides perspectives from an expert trainer regarding this model and provides a photographic and videographic atlas of this model's use in laparoscopy.

Analysis of surgical outcomes and learning curve of surgical parameters for robotic hysterectomy: a comparison between multiport versus single-site

Introduction: The primary goal is to analyze the learning curve of surgical parameters (docking, operation and console time) between multiport and single-site robotic hysterectomy techniques, performed by expert laparoscopic surgeons. Material and methods: The trial is a retrospective analysis of 229 patients enrolled between 2010 and 2018 who underwent robotic hysterectomies with bilateral salpingo-oophorectomies (HBSO) for gynecological diseases. Results: Surgical parameters, learning curve and surgical outcomes were analyzed in order to evaluate the transition from multiport to single-site programs, performed by non-expert surgeons using the multiport technique. All surgical times (total, docking and console time) were shorter in the multiport robotic hysterectomy group, while the intraoperative complication rate was lower in the robotic single-site hysterectomy group (p = 0.007). The learning curve of operative, console and docking time significantly decreased more in the robotic-single site hysterectomy group, than in the multiport robotic hysterectomy group over time (p value < 0.001). Conclusions: The direct transition from the laparoscopy program to the single-site approach is feasible and effective in HBSO performed by expert laparoscopic surgeons. The learning curve of robotic single-site hysterectomy shows that the proficiency in this technique requires more cases than the multiport robotic hysterectomy cases and needs more time to fit the surgical step to the single-site platform.

Laparoscopic hepaticojejunostomy for the treatment of bile duct injuries in difficult scenarios (with video)

Open Roux-en-Y hepaticojejunostomy (RYHJ) is the treatment of choice for bile duct injuries (BDI) sustained during laparoscopic cholecystectomy. Although in recent years the mini-invasive approach has been explored at expert centers, laparoscopic RYHJ for challenging surgical scenarios has rarely been attempted. We herein report two cases of RYHJ for BDI in highly complex surgical scenarios, such as right posterior BDI or failure of previous repairs, with special emphasis on the technical aspects through the embedded videos. The first was an intraoperative repair in a 55-year-old female who suffered a Strasberg type C (transection of the aberrant right hepatic duct) thermal lesion. The second was an iterative repair in a 54-year-old female with a history of a Strasberg type E1 lesion (injury of the main hepatic duct more than 2 cm from the confluence) that had been repaired intraoperatively with an end-to-end anastomosis over a T-tube nine months before referral. Both patients had an uneventful recovery and were discharged four and five days after surgery. After 2.5 and 4 years of follow-up, both patients are asymptomatic and have normal imaging and laboratory tests. To our knowledge, there is no other report in the literature regarding intraoperative laparoscopic right posterior RYHJ for BDI. Laparoscopic RYHJ for BDI repair in the hands of expert laparoscopic biliary surgeons is feasible and safe, even in very challenging surgical scenarios, as herein reported, offering the benefits of mini-invasive surgery. Future high-quality and long-term comparative studies are necessary to elucidate its potential superiority against the standard open approach.

Postural Differences between Expert Laparoscopic and Naïve Surgeons: Implications for Ergonomic Assessment in Surgical Education

<h3>Study Objective</h3> Poor ergonomics can contribute to musculoskeletal disorders and chronic pain for many surgeons which threatens career longevity. This proof-of-concept study sought to quantify upper body postural differences in expert laparoscopic surgeons and naïve surgeons using 3D motion capture during a standardized simulated surgical task. <h3>Design</h3> Observational case-control. <h3>Setting</h3> Motion capture laboratory; Surgical simulation setting. <h3>Patients or Participants</h3> Expert laparoscopic surgeons (n=6) and naïve surgeons (n=9). <h3>Interventions</h3> All participants watched an instructional video prior to data collection and completed the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task three times. The box trainer's height and distance were adjusted to the participants' preference. A 3D motion capture system recorded trajectories of retroreflective markers placed on the participants at various anatomical landmarks. <h3>Measurements and Main Results</h3> Outcome variables of neck, shoulder, elbow, wrist, and trunk angles were computed using a 3D kinematic model. The mean (X) and variance (2 standard deviations from the mean (2SD)) were extracted for each trial and then averaged across trials. Independent T-tests evaluated significant between group differences in body positions in all three planes of motion at the p<0.05 level. Compared to experts, naïve surgeons exhibited significantly greater variation in lateral neck (2SD=5.43±2.35° vs. 3.91±1.72°, p=0.029) and sagittal trunk motion (2SD=3.84±2.57° vs. 1.91±0.91°, p=0.018). Naïve surgeons also performed the task with their elbows significantly more flexed than the expert surgeons (Dominant Arm=96.9±9.2° vs. 82.9±2.1°, p=0.002; Non-Dominant Arm=94.7±8.9° vs. 86.2±8.4°, p=0.043). <h3>Conclusion</h3> Musculoskeletal injury risk factors among laparoscopic surgeons include awkward body posture, static muscle loading, and long operating times. This study demonstrates postural differences of the neck, trunk, and arms between expert and naïve surgeons. Incorporating ergonomic awareness and knowledge into surgical education may help to reduce surgeons' risk of developing cumulative musculoskeletal disorders and enhance surgeon career longevity.

The Use of 3D Motion Capture for the Quantitative Assessment of Surgical Tool Motion in Expert Laparoscopic and Naïve Surgeons

Study Objective This proof-of-concept study sought to evaluate the efficacy of using quantitative variables derived from 3D motion analysis to differentiate laparoscopic surgical skill level. Design Observational case-control. Setting Simulation-based setting; surgical task completion. Patients or Participants Expert laparoscopic surgeons (n=7) and naïve surgeons (n=10). Interventions Participants were recruited to complete the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task. Measurements and Main Results All participants watched an instructional video prior to data collection and completed the task three times. A 3D motion capture system recorded trajectories of retroreflective markers placed on two Maryland graspers and location of surgical tool tips were computed relative to a box trainer. Variables of interest: completion time, surgical tool translation (sagittal, frontal, coronal planes, surgical tool pathlength, and symmetry ratios (non-dominant vs. dominant tool motion). Independent one-tailed T-tests evaluated significant between group differences at the p<0.05 level. Experts completed the task with significantly shorter (mean±stdev) times (119.4±61.7s) (p=0.007) compared to naïve surgeons (201.9±78.4s). This is complemented by significantly shorter tool pathlengths (dominant=195.1±108.7cm; non-dominant=187.1±103.9cm) (p=0.038,0.004) and more symmetrical grasper use (symmetry ratio=0.95±0.19) (p=0.019) in experts compared to naïve surgeons (dominant=297.6±110.7cm; non-dominant=356.9±118.3cm; symmetry ratio=1.24±0.29). No between group differences in surgical tool tip translations were observed. Conclusion 3D motion variables can be used to quantify between group differences in surgical tool motion. Not only did expert surgeons complete tasks more quickly, they also moved more efficiently and displayed more symmetrical use of their hands compared to naïve surgeons, who had greater movement of their non-dominant hands during the task. Objective, quantitative methods allowing trainees to improve surgical skill outside the OR are critical to ensure the highest possible standard of care is provided to patients. However, current evaluation models lack feedback relating to quality of movement. We believe motion capture can be a valuable adjunct to current skills acquisition models to improve self-directed surgical education and resident technicity. This proof-of-concept study sought to evaluate the efficacy of using quantitative variables derived from 3D motion analysis to differentiate laparoscopic surgical skill level. Observational case-control. Simulation-based setting; surgical task completion. Expert laparoscopic surgeons (n=7) and naïve surgeons (n=10). Participants were recruited to complete the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task. All participants watched an instructional video prior to data collection and completed the task three times. A 3D motion capture system recorded trajectories of retroreflective markers placed on two Maryland graspers and location of surgical tool tips were computed relative to a box trainer. Variables of interest: completion time, surgical tool translation (sagittal, frontal, coronal planes, surgical tool pathlength, and symmetry ratios (non-dominant vs. dominant tool motion). Independent one-tailed T-tests evaluated significant between group differences at the p<0.05 level. Experts completed the task with significantly shorter (mean±stdev) times (119.4±61.7s) (p=0.007) compared to naïve surgeons (201.9±78.4s). This is complemented by significantly shorter tool pathlengths (dominant=195.1±108.7cm; non-dominant=187.1±103.9cm) (p=0.038,0.004) and more symmetrical grasper use (symmetry ratio=0.95±0.19) (p=0.019) in experts compared to naïve surgeons (dominant=297.6±110.7cm; non-dominant=356.9±118.3cm; symmetry ratio=1.24±0.29). No between group differences in surgical tool tip translations were observed. 3D motion variables can be used to quantify between group differences in surgical tool motion. Not only did expert surgeons complete tasks more quickly, they also moved more efficiently and displayed more symmetrical use of their hands compared to naïve surgeons, who had greater movement of their non-dominant hands during the task. Objective, quantitative methods allowing trainees to improve surgical skill outside the OR are critical to ensure the highest possible standard of care is provided to patients. However, current evaluation models lack feedback relating to quality of movement. We believe motion capture can be a valuable adjunct to current skills acquisition models to improve self-directed surgical education and resident technicity.

Assessment of difficulty in laparoscopic distal pancreatectomy: A modification of the Japanese difficulty scoring system - A single-center high-volume experience.

BackgroundThe Japanese difficulty scoring system (DSS) was developed to assess the difficulty of laparoscopic distal pancreatectomy (LDP). The study aimed to validate a modified DSS (mDSS) in a European high‐volume center.MethodsPatients' clinical data underwent LDP for benign and malignant pancreatic lesion between September 2013 and February 2020 were reviewed. Expert laparoscopic surgeons performed the procedures. The mDSS consisted of seven variables, such as type of operation, malignancy, neoadjuvant therapy, pancreatic resection line, tumor close to major vessels, tumor extension to peripancreatic tissue, and left‐sided portal hypertension and/or splenomegaly. According to the difficulty level and previous score, the mDSS was subdivided into three classes: low, intermediate, and high. Surrogates of case complexity (operative time, intraoperative blood loss and blood transfusion requirements, conversion rate) were used to validate the new scoring system.ResultsThe study population included 140 LDP. Ninety‐five (68%), 35 (25%) and 10 (7%) patients belonged to low, intermediate, and high difficulty groups. The mDSS identified the complexity of the surgical case of the series for all the surrogates of complexity considered, namely conversion rate (P = .004), operative time (P = .033) and intraoperative blood loss (P = .009). No differences were recorded in the postoperative outcomes (P > .05).ConclusionThe mDSS for LDP better stratified the pancreatic procedures according to their complexity. The new scoring system may allow an appropriate preoperative evaluation of surgical difficulty, facilitating LDP's training program. Future prospective studies are needed to validate the mDSS.

How many procedures are needed to achieve learning curve of Millin simple laparoscopic prostatectomy?

Aim of our study was to evaluate learning curve of the Millin simple prostatectomy analysing three expert laparoscopic surgeons. Learning curve of 3 expert laparoscopic surgeons with excellent radical prostatectomy training was evaluated. Surgeon 1 had more than 20 years of experience, while other surgeons had 10 years of experience. The first 45 procedures of the surgeons were considered for analysis. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted to analyse learning curves. The variables included to evaluate learning curve of the surgeons were: operative time (OT), hospitalisation (HO) and complication rate. Overall 135 patients were included in the analysis. Median age was 68 (64/74), median prostate volume was 83 (75/97), median Qmax 9 ml/s (6/11) and median IPSS 20 (18/22). Complications included: 9/135 (7%) transfusion, 4/135 (3%) Urinary retention, 3/135 (2%) fever, 1/35 (<1%) reintervention and 1/135 (<1%) conversion. Surgeon 1 presented a lower median operative time when compared to surgeon 2 and 3. No significant differences were recorded in terms of hospitalisation, blood loss and transfusion rate as well as postoperative outcomes. According to the CUSUM analysis the number of procedures needed to achieve a plateau in surgical time is 10/15 procedures (fig 1). In conclusion, according to our results 15 procedures are needed to reach a plateau in surgical time for trained laparoscopic surgeons.

Intra-abdominal Breakage of Laparoscopic Needle Holder Tip and Its Retrieval Under Fluoroscopic Guidance.

Intra-operative breakage of laparoscopy instruments is a rare occurrence. It entails a risk of the foreign body being retained in the abdomen and may lead to medico-legal implications. The foreign body migrates due to bowel movements. Therefore, the retrieval of such foreign bodies can be challenging even for a highly skilled and experienced surgeon. Fluoroscopy can guide in locating the missing foreign body. The only preventive measure is the vigilance of the operating team and thorough inspection of all the instruments prior to completion of surgery. We present a case report of a 50-year-old lady who underwent total laparoscopic hysterectomy with bilateral salpingoopherectomy at a private nursing home. During the closure of the vault, the tip of the needle holder broke inside the abdomen and the primary surgeon was unable to retrieve it. The missing tip of the needle holder was removed from the right hypochondriac region, by a second laparoscopic surgery by an advanced laparoscopic surgeon under fluoroscopic guidance. Intra-operative breakage of laparoscopy instruments can occur, demanding a great deal of expertise for the retrieval of such foreign bodies. Fluoroscopy can guide in locating the missing foreign body which can be retrieved by an expert laparoscopic surgeon.

Two-dimensional (2-D) vs. three-dimensional (3-D) laparoscopic right hemicolectomy with intracorporeal anastomosis for colon cancer: comparison of short-term results.

There are few reports comparing safety and efficacy of 2-D and 3-D video technology in laparoscopic right hemicolectomy. The aim of the study was to assess the short-term results of laparoscopic right hemicolectomy (LHR) with intracorporeal anastomosis with 2-D/3-D video in patients with right colon cancer. Data from 239 patients undergoing LRH for cancer in a 14-year period (June 2005-January 2020) were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. One hundred and fourteen patients were included in the study: 55 (48.2%) operated with 2-D and 59 (51.8%) with 3-D video. Tumor site and postoperative stage distribution were similar. Mean operative time was comparable in the two groups (159.0 ± 48.8min vs. 17.06 ± 36.0min, p = ns, group 2-D and 3-D, respectively). Group 3-D patients had a similar percentage of associated procedures (44.1% vs. 29.1%, p = ns). Intraoperative complications were nil in both groups, while postoperative complications were similar (30.9% 2-D vs 25.4% 3-D, p = ns). The mean number of lymph nodes retrieved was similar in group 3-D (26.0 ± 14.6 vs. 22.9 ± 9.3, p = ns) and the length of stay was comparable in 3-D and 2-D patients (8.4 ± 2.6 vs. 9.1 ± 3.3days, respectively, p = ns). Laparoscopic 3-D vision is as equally effective as 2-D vision in LRH with intracorporeal anastomosis, with a similar proportion of associated procedures and number of lymph nodes retrieved in the same operative time. Further prospective larger randomized studies are necessary to verify if LRH with 3-D video can reduce postoperative complications, compared to 2-D video.

Laparoscopic Completion Cholecystectomy for Residual Gallbladder and Cystic Duct Stump Stones: Our Experience and Review of Literature

Post cholecystectomy syndrome (PCS) is a term used for the persistence of antecedent symptoms following cholecystectomy. The etiology is mainly non-biliary but remnant gallbladder or cystic duct stump calculi may be the cause in some patients. Ultrasonography is the initial imaging modality but MRCP provides a more accurate diagnosis and serves as a roadmap during surgery. Such patients need a completion cholecystectomy for relieving their symptoms. The study included 41 patients who underwent laparoscopic completion cholecystectomy (LCC) at two health institutions of our state by the same team of operating surgeons over a period of 7 years from January 2013 to December 2019. All the patients included had previously undergone open cholecystectomy at different health centers and reported to us with PCS. The data regarding presentation, imaging, intraoperative findings, complications, and follow-up after LCC were noted and analyzed. Laparoscopic completion cholecystectomy was successfully done in 38 patients (92.6%) and 3 (7.3%) cases had to be converted to open procedure. No major bile duct injury was encountered in any case and there were no mortalities. The majority of the patients (36 patients 87.8%) had complete resolution of symptoms after completion cholecystectomy. Laparoscopic completion cholecystectomy in the hands of an expert laparoscopic surgeon is a safe alternative with good outcomes and acceptable complication rates.

Learning curve in robotic colorectal surgery.

With the rapid adoption of robotics in colorectal surgery, there has been growing interest in the pace at which surgeons gain competency, as it may aid in self-assessment or credentialing. Therefore, we sought to evaluate the learning curve of an expert laparoscopic colorectal surgeon who performed a variety of colorectal procedures robotically. This is a retrospective review of a prospective database of 111 subsequent colorectal procedures performed by a single colorectal surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing total operative and console times. Postoperative outcomes including length of stay, 30-day complications, and 30-day readmission rates were evaluated. Chi-square and one-way ANOVA (including Kruskal-Wallis) tests were used to evaluate categorical and continuous variables. Our patient cohort had a mean age of 62.4, mean BMI of 26.9, and mean ASA score of 2.41. There were two conversions to open surgery. The CUSUM graph for console time indicated an initial decrease at case 13 and another decrease at case 83, generating 3 distinct performance phases: learning (n = 13), competence (n = 70), and mastery (n = 28). An interphase comparison revealed no significant differences in age, gender, BMI, ASA score, types of procedures, or indications for surgery between the three phases. Over the course of the study, both mean surgeon console time and median length of stay decreased significantly (p = 0.00017 and p = 0.016, respectively). Although statistically insignificant, there was a downward trend in total operative time and postoperative complication rates. Learning curves for robotic colorectal surgery are commonly divided into three performance phases. Our findings contribute to the construction of a reliable learning curve for the transition of colorectal surgeons to robotics. Furthermore, they may help guide the stepwise training and credentialing of new robotic surgeons.

Educational system for acquiring appropriate laparoscopic colorectal surgical skills: analysis in a Japanese high-volume cancer center.

Acquiring appropriate laparoscopic technique is necessary to safely perform laparoscopic surgery. The Endoscopic Surgical Skill Qualification System of the Japanese Society of Endoscopic Surgery, which was established to improve the quality of laparoscopic surgery in Japan, provides training to become an expert laparoscopic surgeon. In this study, we describe our educational system, in a Japanese highest volume cancer center, and evaluate the system according to the pass rate for the Endoscopic Surgical Skill Qualification System examination. We assessed 14 residents who trained for more than 2years from 2012 to 2018 in our department. All teaching surgeons, qualified by the Endoscopic Surgical Skill Qualification System, participated in all surgeries as supervisors. For the first 3months, trainees learned as the scopist, then as the first assistant for 3months, and then by performing laparoscopic surgery as an operator during ileocecal resection or sigmoidectomy. Trainees apply for this training in their second year of residency or later. All laparoscopic procedures in our department are standardized in detail. The cumulative pass rate was 75% (12/16), and 87% (12/14) of the trainees eventually passed, while the general pass rate was approximately 30%. On average, those who passed in their second or third year had experienced 94 procedures as the surgeon, 177 as the first assistant, and 199 as the scopist. The number of laparoscopic procedures and the learning curves did not differ between successful and failed applicants. Through our educational system, residents successfully acquired laparoscopic skills with a much higher pass rate in the Endoscopic Surgical Skill Qualification System examination than the general standard. Laparoscopic practice under supervision by experienced surgeons with standardized procedures and accurate understanding of the relevant anatomy is very helpful to achieving appropriate laparoscopic technique.

Practicing on the Advanced Training in Laparoscopic Suturing Curriculum (ATLAS): Is Mastery Learning in Residency Feasible to Achieve Expert-Level Performance in Laparoscopic Suturing?

Mastery learning assumes that given enough time and appropriate instructional strategies, most trainees will be able to achieve proficiency. Expert-level performance requires numerous hours of intensive and focus practice. We aimed to study whether it was possible for surgical trainees to achieve expert-derived proficiency level in laparoscopic suturing using the Advanced Training in Laparoscopic Suturing (ATLAS) curriculum over a short period of time. A multicenter IRB approved prospective study included surgery residents and minimally invasive fellows. Participants underwent weekly supervised instruction and assessments of ATLAS skills and self-directed practice between sessions over 12 weeks. Participants were asked to practice until they achieved previously established proficiency benchmarks of expert laparoscopic surgeons. Fifteen participants, PGY2 to PGY6, from 3 institutions practiced on the ATLAS curriculum. Three participants were able to achieve proficiency on the entire curriculum, with a cumulative practice time varying between 3.4 and 7.6 hours. Individual tasks had varying degrees of difficulty ranging from 85% proficiency on task 1 to 33.3% proficiency for task 6. Using a mixed-method model, the mean cumulative hours of practice to reach the benchmark threshold was estimated for each task and varied from 4.5 to 13.2 hours. The improved performance was associated with higher PGY level and proficiency in FLS. This study demonstrates that it is possible for some senior surgical trainees to achieve proficiency in an expert-level laparoscopic suturing curriculum. This study establishes a learning curve for each ATLAS individual task. Some learners may not be able to achieve proficiency on the entire curriculum over a short period of practice. Additional studies are needed to assess how to shorten the learning curve with effective instructional methods such as expert-guided training with immediate feedback.

What are the skills that represent expert-level laparoscopic suturing? A Delphi Study.

As the field of laparoscopic surgery grows, the need for a valid assessment of laparoscopic surgical skills becomes apparent. The objective of this study was to identify laparoscopic suturing skills reflective of performing at an expert level. A Delphi Study was conducted with expert laparoscopic surgeons. Tasks were considered to meet criteria for consensus after 80% of survey participants answered "strongly agree." Results of the previous round of surveys were shared with participants at the start of the next round. The predefined endpoint for the Delphi was set as maximum of three rounds, reaching 80% consensus on each skill, or if > 50% of initial respondents fail to return for subsequent surveys. After three rounds of surveys completed by 13 advanced laparoscopic surgeons, 8 observed skills met consensus (> 80% selected "strongly agree"): forehand suturing, continuous suturing, avoiding tissue trauma, achieving a technically acceptable final product (tight closure), tying a secure knot at the end of suturing, maintaining/checking for appropriate tightness of running suture, accurate depth perception, and loading the needle in < 3 attempts. Skills that approached consensus (with > 50% ranking them as "strongly agree") included correct penetration of target tissue, ability to create a surgeon's knot, awareness of needle tip position, confined space suturing, following the curve of the needle, smooth movements of instruments, loading the needle correctly, adjusting for tissue thickness, and bimanual dexterity. Using Delphi methodology, we identified the skills that are representative of expert laparoscopic suturing. This information can be used to create an assessment tool for this domain. Validation of such a tool will help advance the surgical field towards true competency-based assessment of expertise.

Added value of 3D-vision during laparoscopic biotissue pancreatico- and hepaticojejunostomy (LAELAPS 3D2D): an international randomized cross-over trial

BackgroundIt is currently unclear what the added value is of 3D-laparoscopy during pancreatic and biliary surgery. 3D-laparoscopy could improve procedure time and/or surgical performance, for instance in demanding anastomoses such as pancreatico- and hepaticojejunostomy. The impact of 3D-laparoscopy could be negligible in more experienced surgeons. MethodsWe conducted a randomized controlled cross-over trial including 20 expert laparoscopic surgeons and 20 surgical residents from 9 countries (Argentina, Estonia, Israel, Italy, the Netherlands, South Africa, Spain, UK, USA). All participants performed a pancreaticojejunostomy (PJ) and a hepaticojejunostomy (HJ) using 3D- and 2D-laparoscopy on biotissue organ models according to the Pittsburgh method. Primary endpoint was the time required to complete both anastomoses. Secondary endpoint was the objective structured assessment of technical skill (OSATS; range 12–60) rating. Observers were blinded for 3D/2D and expertise. ResultsA total of 40 participants completed 144 PJs and HJs. 3D-laparoscopy reduced the operative time with 15.5 min (95%CI 10.2–24.5 min), from 81.0 to 64.4 min, p = 0.001. This reduction was observed for both experts and residents (13.0 vs 22.2 min, intergroup significance p = 0.354). The OSATS improved with 5.1 points, SD ± 6.3, with 3D-laparoscopy, p = 0.001. This improvement was observed for both experts and residents (4.6 vs 5.6 points, p = 0.519). Of all participants, 37/39 participants stated to prefer 3D laparoscopy whereas 14/39 reported side effects. Minor side effects were reported by 10/39 participants whereas 2/39 participants reported severe side effects (both severe eye strain). Conclusion3D-laparoscopy, as compared to 2D-laparoscopy, reduced the operative time and improved surgical performance for PJ and HJ anastomoses in both experts and residents with mostly minor side effects.

The effect on surgical skills of expert surgeons using 3D/HD and 2D/4K resolution monitors in laparoscopic phantom tasks.

Recently, several new imaging technologies, such as three-dimensional (3D)/high-definition (HD) stereovision and high-resolution two-dimensional (2D)/4K monitors, have been introduced in laparoscopic surgery. However, it is still unclear whether these technologies actually improve surgical performance. Participants were 11 expert laparoscopic surgeons. We designed three laparoscopic suturing tasks (task 1: simple suturing, task 2: knotting thread in a small box, and task 3: suturing in a narrow space) in training boxes. Performances were recorded by an optical position tracker. All participants first performed each task five times consecutively using a conventional 2D/HD monitor. Then they were randomly divided into two groups: six participants performed the tasks using 3D/HD before using 2D/4K; the other five participants performed the tasks using a 2D/4K monitor before the 3D/HD monitor. After the trials, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and compared performance scores across all monitors. Surgical performances of participants were ranked in decreasing order: 3D/HD, 2D/4K, and 2D/HD using the total scores for each task. In task 1 (simple suturing), some surgical performances using 3D/HD were significantly better than those using 2D/4K (P = 0.017, P = 0.033, P = 0.492 for operative time, path length, and technical errors, respectively). On the other hand, with operation in narrow spaces such as in tasks 2 and 3, performances using 2D/4K were not inferior to 3D/HD performances. The high-resolution images from the 2D/4K monitor may enhance depth perception in narrow spaces and may complement stereoscopic vision almost as well as using 3D/HD. Compared to a 2D/HD monitor, a 3D/HD monitor improved the laparoscopic surgical technique of expert surgeons more than a 2D/4K monitor. However, the advantage of 2D/4K high-resolution images may be comparable to a 3D/HD monitor especially in narrow spaces.