Increasing Surgeon Experience Research Articles

Association Among Surgeon Experience, Patient Risk, and Outcomes in Coronary Artery Bypass Grafting

There is an association between surgeon experience and outcomes after cardiac surgery. However, this association is not well studied in the context of patient risk. The purpose of this single-center, retrospective, observational study was to describe how surgeon experience relates to patient risk in isolated coronary artery bypass grafting (CABG) surgery and how this impacts patient outcomes. Surgeon experience was defined as time between the surgeon finishing fellowship and date of the patient's surgery. Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) was used to define patient risk. The Kaplan-Meier method was used to calculate long-term survival, and multivariable Cox proportional hazards regression was used to determine the effect of surgeon experience on survival. Between 2002 and 2018, 7652 patients underwent isolated CABG. STS PROM was 1.35% (interquartile range [IQR], 0.70%-2.80%), 1.55% (IQR, 0.79%-3.34%), 1.78% (IQR, 0.84%-3.84%), and 1.19% (IQR, 0.62%-2.41%) in surgeon experience quartiles 1 (0.01-6.05 years), 2 (6.05-11.5 years), 3 (11.5-16.6 years), and4 (16.6-32.1 years), respectively (P < .001). For patientsin the lowest PROM quartile, Kaplan-Meier survival was similar across surgeon experience groups (P= .66). For patients in the highest PROM quartile, increasing surgeon experience was associated with better survival (P < .001). Cox regression identified surgeon experience as a protective factor (hazard ratio, 0.99, P=.027). In the least experienced surgeon group, increased ejection fraction was a protective factor for long-term survival (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99). Increasing surgeon experience is associated with higher-risk patients, but the most experienced surgeons take on lower-risk patients. Greater experience correlates with improved outcomes, especially with higher-risk cases.

Robotic versus Laparoscopic Cholecystectomy: Case-Control Outcome Analysis and Surgical Resident Training Implications.

BackgroundThe robotic approach in surgery is becoming more widely used in many subspecialties. Robot-assisted laparoscopic procedures provide potential improvements in clinical outcomes due to improved visualization and enhanced surgical ergonomics. In this study, we measured and compared outcomes of robot-assisted laparoscopic cholecystectomy with the conventional laparoscopic technique, as well as the implications for the training of surgical residents.MethodWe compared a total of 244 patients undergoing minimally invasive cholecystectomies performed by one surgeon between July 2013 and June 2016 examining relevant clinical outcomes including operative room (OR) time, length of hospital stay (LOS), readmission to the hospital, post-operative emergency department (ED) visits, and post-operative pain between laparoscopic single-incision cholecystectomy and robot-assisted laparoscopic cholecystectomy. A chi-square test and Student’s t-test were used to compare these variables between the two groups. Propensity score matching (PSM) was used using gender, age, and body mass index (BMI) as variables.ResultsFrom the total number of procedures of 244, 144 were included in the laparoscopic group and 100 in the robot-assisted group. The robot-assisted patients had a shorter post-operative LOS (mean: 0.8 vs. 1.6 days; p = 0.002). There was no significant difference in the OR time (mean: 64.8 vs. 65.0 minutes; p = 0.945), readmissions (4.0% vs. 3.5%; p = 0.830), post-operative ED visits (7.0% vs. 7.6%; p = 0.851), or post-operative pain (13.0% vs. 21.3%; p= 0.137). Robotic cholecystectomy patients were younger (mean: 46 vs. 52 years; p = 0.023) and had lower BMIs (mean: 31 vs. 33; p = 0.038). Because of these differences, we compared the two groups using PSM that confirmed the shorter LOS in the robotic group (mean: 0.9 vs. 1.9; p = 0.009).ConclusionsThese results demonstrate that robotic cholecystectomies can reduce LOS for patients undergoing laparoscopic cholecystectomy, without increasing OR time. Increased surgeon experience with robotic procedures and improved OR efficiency will allow greater opportunities for resident participation. Robotic training curricula need to be employed and objectively evaluated to improve surgical resident skill acquisition and provide earlier and progressive clinical participation in robotic procedures.

V13-07 STANDARDIZED TENSIONING TECHNIQUE FOR AUTOLOGOUS PUBOVAGINAL SLINGS

You have accessJournal of UrologyFemale Pelvic Surgery (V13)1 Apr 2020V13-07 STANDARDIZED TENSIONING TECHNIQUE FOR AUTOLOGOUS PUBOVAGINAL SLINGS Alan Quach*, Michael Maccini, David Koslov, Kirk Redger, and Brian Flynn Alan Quach*Alan Quach* More articles by this author , Michael MacciniMichael Maccini More articles by this author , David KoslovDavid Koslov More articles by this author , Kirk RedgerKirk Redger More articles by this author , and Brian FlynnBrian Flynn More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000970.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recent FDA public health notifications have created increased utilization of autologous pubovaginal slings (PVS). Unlike midurethral slings, there is no standardization in tensioning methods of autologous fascial slings, leading to increased rates of postoperative urinary retention (10%). Consequently we have made efforts to standardize our technique to lesson the risk of retention in this population. METHODS: Since 2013, we have adopted a standardized tensioning technique. Briefly, a rubber shod is placed on the suspension sutures at the level of the fascia bilaterally. A second rubber shod is placed at a defined distance above the fascia and the suspension sutures are tied. This predetermined distance is as follows: 0 cm spacing for occlusive slings, 1 cm spacing for patients with severe ISD, and 2 cm spacing for the remaining population. In this video we will demonstrate autologous rectus fascial harvest and our standardized rubber shod tensioning technique in a 53 year old female with recurrent stress urinary incontinence following removal of exposed transvaginal mesh. RESULTS: In 168 patients, our overall SUI cure rate (<1 pad per day) was 78%. The standardized tensioning group had a decreased risk of both postoperative retention and sling lysis (OR = 0.41 and 0.22, respectively). Increasing surgeon experience did not demonstrate an independent association with postoperative retention. CONCLUSIONS: Our standardized tensioning technique for autologous PVS reduces the risk of postoperative retention and sling lysis while maintaining excellent continence outcomes. This technique offers reproducible tensioning which could reduce the learning curve for autologous PVS procedures. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1212-e1212 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alan Quach* More articles by this author Michael Maccini More articles by this author David Koslov More articles by this author Kirk Redger More articles by this author Brian Flynn More articles by this author Expand All Advertisement PDF downloadLoading ...

Learning curve of septoplasty procedure

Objectives: The aim of this study was to investigate possible relationship between surgical experience and septoplasty-related data and to determine the learning curve based on surgery duration. Patients and Methods: The first 60 septoplasty patients of four Ear, Nose and Throat residents who completed an 18-month residency training in our clinic between August 2015 and December 2017 were included in the study. A total of 240 patients (155 males, 85 females; mean age 32.8±10.6 years; range, 17 to 60 years) were evaluated. The first 10 patients were grouped as Group A, 11-20 patients as Group B, 21-30 patients as Group C, 31-40 patients as Group D, 41-50 patients as Group E, and 51-60 patients as Group F. The patients’ files were retrospectively reviewed to obtain information on demographics, postoperative hospital stay, complications, revision operation requirements, and operation time. The mean operation time was calculated. Duration of surgery was used to evaluate the maturity of surgical skills. Results: The mean operation time was 60.0±17.3 min. The mean operation times of the patients in Group A and Group B were significantly longer than that of the patients in Group C, Group D, Group E, and Group F. There was no significant difference between the groups in terms of length of hospital stay, complications, and revision rates. Conclusion: As the surgeon's experience increases, the operation time decreases, and after 20 patients, it reaches the plateau level. Based on these data, it can be concluded that ENT residents should practice more than 20 patients to learn the septoplasty procedure sufficiently.

Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Analysis.

Background:Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system.Methods:This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon’s initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes.Results:Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 – 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 – 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups.Conclusion:Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Intraoperative radiation exposure in hip arthroscopy: a systematic review.

Fluoroscopy is used in hip arthroscopy (HA) for portal placement, instrument localisation, and guidance in bony resection. The recent increase in arthroscopic hip procedures may place patients and surgeons at risk for increased radiation exposure and radiation-induced complications. The purpose of the current systematic review was to assess intraoperative radiation exposure in HA. The systematic review was conducted according to PRISMA guidelines; inclusion criteria were studies assessing radiation exposure in HA. 9 studies including 994 patients were included. Mean age was 38.6 years and 48% (436 of 906) were female. Mean time of fluoroscopy exposure was 0.58 minutes. Dose area product was 129.5 cGycm2. Mean intraoperative absorbed radiation dose studies was 12.6 mGy. Mean intraoperative effective dose was 0.48 mSv. The mean occupational exposure to the surgeon per case was 0.0031 mSv. Higher patient body mass index (BMI) correlated to greater patient effective and cumulative dose (p < 0.05, r = 0.404), and greater occupational exposure (p < 0.001, r = 0.460). Increasing surgeon experience decreased fluoroscopy time (p = 0.039) and radiation dose (p = 0.002). Radiation dose and effective dose were well under the thresholds for deterministic effects (2 Gy) and annual radiation exposure for occupational workers (20 mSv). Intraoperative radiation exposure to patients and surgeons is within acceptable annual radiation limits. Ensuring careful selection of perioperative imaging modalities, proper protective shielding, specifically the use of leaded eyeglasses, and optimal C-arm positioning are key strategies to reduce radiation exposure to patients and surgeons alike.

Sedation and paralytic use in open abdomen patients—results from the EAST SLEEP Survey

BackgroundPatients with an open abdomen after trauma or emergency surgery may benefit from reduced sedation and chemical paralysis. We studied the effect of attending surgeon experience on sedation depth and paralytic use, as well as enteral nutrition and time between laparotomies. MethodsWe performed an institutional review board-approved survey (Sedation Level after Emergent ExLap without Primary Fascial Closure) of the senior and active Eastern Association for the Surgery of Trauma membership using Qualtrics (Qualtrics, Inc, Provo, UT). We obtained 393/1,655 responses (23.7%). Spearman’s rho was used for ordinal data, and multivariate logistic regression was used to adjust for trauma center level and presence of trainees in the relationship between surgeon experience and use of deep sedation. ResultsSurgeon experience was associated with deep sedation (Richmond Agitation and Sedation Score ≤–3, P = .001) and chemical paralysis (P = .001). Surgeon experience was associated with less concern about delirium and more concern for evisceration as the reason for sedation depth (P = .001) and for paralysis (P = .001). Using multivariate logistic regression, surgeon experience was associated with deep sedation (odds ratio 3.6 [95% confidence interval 1.3, 10.4], P = .017 for ≥20 years; odds ratio 3.5 [95% confidence interval 1.1, 10.4], P = .025 for 15–20 years). Trauma center level was also significant (odds ratio 7.2 for Richmond Agitation and Sedation Score ≤–3 [95% confidence interval 1.7, 31.0], P = .008 for level III/IV versus level I/II). Increased surgeon experience was associated with delay of commencement of enteral feeds until return of bowel function (P = .013). Few respondents indicated willingness to extubate or mobilize open abdomen patients. Experienced surgeons were likely to wait for a defined time rather than for normalization of resuscitation markers to perform the first takeback laparotomy (P = .047) and waited longer between subsequent laparotomies (P = .004). ConclusionThere were significant variations in practice among respondents based on the length of time since their last residency or fellowship, including variations that deviate from current best practice for management of patients with an open abdomen.

Epidemiology of Bearing Dislocations After Mobile-Bearing Unicompartmental Knee Arthroplasty: Multicenter Analysis of 67 Bearing Dislocations

BackgroundThis study investigated the epidemiology and causes of bearing dislocations following mobile-bearing unicompartmental knee arthroplasty (MUKA) and determined whether the incidence of primary bearing dislocations decreases as surgeon experience increases. MethodsWe retrospectively reviewed the bearing dislocations following MUKAs performed by 14 surgeons with variable experience levels. Causes of bearing dislocations were determined based on the surgical records, radiographs, and operator’s suggestion. Using a chi-squared test, the incidence of bearing dislocation was compared between the first 50, the second 50, and the next 100 unicompartmental knee arthroplasties (UKAs) of each surgeon's cohort. ResultsThere were 67 (3.6%) bearing dislocations from 1853 MUKAs. The mean time to bearing dislocations after index MUKAs was 33 months (range, 1-144 months); 55% of the bearing dislocations occurred within 2 years after the index MUKAs. Primary bearing dislocations (n = 58) were the most common, followed by secondary (n = 6) and traumatic dislocations (n = 3). There was no significant difference in the incidence of bearing dislocation between the first 50 and second 50 UKAs for each surgeon. Two surgeons showed a significant decrease in bearing dislocations in their second 100 UKAs, while the other surgeons did not show a difference between their first 100 and second 100 UKAs. ConclusionMost bearing dislocations after MUKAs were related to technical errors such as component malposition or gap imbalance. This study did not confirm that the incidence of bearing dislocations decreases as the number of cases increases. Level of EvidenceIV, Case series.

The effect of surgeon experience on tympanic membrane closure.

ObjectiveReview of the English language literature finds little documentation of the relation of otology or otolaryngology outcomes to a surgeon's age, years in practice, or numbers of cases previously performed. Because of one surgeon's adoption of a new tympanoplasty technique for uncomplicated tympanic membrane perforations, our institution was situated to report an example of a surgical learning curve with its outcome. Experience versus outcome is worth establishing objectively because these relationships reflect on training and certification.DesignThis retrospective review of the medical records tallied preoperative risk factors and perforation sizes for four consecutive 100‐blocks of double‐layer tympanoplasties.SettingAn otology specialty care facility in Addis Ababa, Ethiopia.ParticipantsParticipants were 359 patients with tympanic membrane perforations without ossicular discontinuity or erosion who underwent 400 primary simple tympanoplasties.InterventionA double‐layer tympanoplasty was performed in each operation using an endaural approach.Outcome MeasuresThe outcomes were closure of the perforation and change in hearing.ResultsThere were no statistically significant differences between the four 100‐block case cohorts in preoperative risk factors and perforation sizes. Preoperative, postoperative, and change of hearing were also the same between the four groups; and statistically there was no significant difference between the four 100‐block cohorts. Perforation closure for each successive 100‐block increased from 74% to 98%. The closure rates of the second, third, and fourth 100‐block were each statistically significantly different from the first 100‐block, but not from each other.ConclusionThis simple study demonstrates the surgical learning curve with increased surgeon experience, and is one of very few such documentations. With each additional 100 cases, the outcomes improved, and sheds light on the numbers of cases necessary for competency.Level of Evidence3

The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon's experience with 197 cases

BACKGROUND CONTEXTThree-column osteotomy (3CO) is used to correct rigid adult spinal deformity. It presents risk of complications because it involves extensive osseous resection and spinal destabilization. PURPOSEOur purpose was to characterize the learning curve for performing 3CO in adult spinal deformity patients. DESIGNRetrospective review. PATIENT SAMPLEA surgical registry at a tertiary care center was used to identify 238 cases of 3CO for correction of adult spinal deformity by 1 surgeon between 2005 and 2014. Patients with at least 1 year of clinical and radiographic follow-up were included (n=197; mean duration of follow-up, 43 months; range, 12–121). OUTCOME MEASURESWe quantified associations between surgeon experience and (1) estimated blood loss per vertebral level fused (EBL/VLF), (2) incidence of new neurologic deficits, (3) incidence of reoperation for instrumentation failure, (4) operative time in minutes, and (5) magnitude of correction at the level of the osteotomy. METHODSThe learning curve for binary outcomes was demonstrated using a LOWESS smoother plot of the probability of occurrence. Change in risk was calculated using a generalized linear model with link identity and binomial family. The learning curve for continuous variables was demonstrated using a scatter plot and a line of best fit based on linear regression analysis. Alpha=0.05. RESULTSEBL/VLF decreased by a mean of 19.7 mL (95% confidence interval [CI]: 11.3–28.1) with each 10 cases (decrease of 388 mL/level fused by the end of the study period). The risk of a neurologic deficit declined by 7.98% (95% CI: 7.98%, 7.99%) with every 100 cases. The risk of reoperation declined by 1.99% (95% CI: 0.83%, 3.17%) with every 10 cases until the 100th case. After that point, there was no significant change in the probability of reoperation (p>.05). The magnitude of correction and operative time did not change with increasing surgeon experience (p>.05). CONCLUSIONIncidence of reoperation for instrumentation failure, incidence of new neurologic deficits, and estimated blood loss improved with increasing surgeon experience at performing 3CO. Most outcomes, except the risk of reoperation, improved through the last case.

Intra- and interobserver reliability of the Spinal Instability Neoplastic Score system for instability in spine metastases: a systematic review and meta-analysis.

Mechanical instability is one of the two main indications for surgical intervention in patients with metastatic spine disease. Since its publication in 2010, the Spinal Instability Neoplastic Score (SINS) has been the most commonly used means of assessing mechanical instability. To prove clinically valuable though, diagnostic tests must demonstrate consistency across measures and across observers. Here we report a systematic review and meta-analysis of all prior reports of intraobserver and interobserver reliability of the SINS score. To identify articles, we queried the PubMed, CINAHL, EMBASE, Cochrane, and Web of Science databases for all full-text English articles reporting interobserver or intraobserver reliability for the SINS score, category, or a domain of the SINS score. Articles reporting confidence intervals for these metrics were then subjected to meta-analysis to identify pooled estimates of reliability. Of 167 unique studies identified, seven met inclusion criteria and were subjected to qualitative review and meta-analysis. Intraobserver reliability for SINS score was found to be near perfect [estimate =0.815; 90% CI (0.661-0.969)] and interobserver reliability was substantial [0.673; (0.227-1.12)]. Intraobserver and interobserver reliability among spine surgeons was significantly better than reliability across all observers (both P<0.0001). Qualitative analysis suggested that increased surgeon experience may be associated with greater intraobserver and interobserver reliability among spine surgeons. On the whole, meta-analysis of the available literature suggests SINS to have good intraobserver and interobserver reliability, giving it the potential to be a valuable guide to the management of patients with spinal metastases. Further research is required to demonstrate that SINS score correlates with the clinical decision to stabilize.

Risk of empty lymph node packets in sentinel lymph node mapping for endometrial cancer using indocyanine green.

To determine whether the rate of sentinel lymph node (SLN) dissections that do not yield a lymph node on pathological analysis ('empty packet dissection') changes with increasing surgeon experience in the setting of patients undergoing minimally invasive hysterectomy and SLN mapping using indocyanine green dye for endometrial cancer. All patients undergoing SLN mapping using indocyanine green dye at the time of minimally invasive hysterectomy for endometrial cancer or complex atypical hyperplasia were identified between January 2013 and September 2017 at our institution. All surgeons had prior experience performing SLN mapping for endometrial cancer using other methods. The rate of empty packet dissections and SLN counts were evaluated using a logistic regression model analysis. In total, 236 patients undergoing SLN mapping for either endometrial cancer (85%) or complex atypical hyperplasia (15%) were identified from a prospectively maintained database. When examining all six surgeons together, the percentage of empty packet dissections decreased with increasing number of procedures performed. Each additional procedure was associated with a 3.6% reduction in the odds of an empty packet SLN dissection. After adjusting for individual surgeons, each additional procedure was associated with a 4.9% reduction in the odds of an empty packet. The expected odds of an empty packet after 10 additional procedures decreased by 40.1% (95% CI 12.4% to 58.6%). The addition of two covariates (age and body mass index) did not contribute significantly to the model (likelihood ratio test: X2=2.75, p=0.25). The rate of empty packets appeared to stabilize after approximately 30 procedures. The number of SLNs removed did not change with increasing surgeon experience. The rate of empty packet SLN dissections using indocyanine green dye decreases with increasing number of procedures. This stabilizes after 30 procedures, suggesting completion of a learning curve.

Are we getting any better? A study on repair integrity in 1600 consecutive arthroscopic rotator cuff repairs

BackgroundPostoperative retear is the most common surgical complication after rotator cuff repair. This study aimed to determine whether there had been any improvements in rotator cuff repair integrity in our center and to identify any changes in the management of rotator cuff tears that may have impacted postoperative retear rate.MethodsThis retrospective observational single cohort study used running average analysis to examine 1600 consecutive patients over 8 years, who underwent primary arthroscopic rotator cuff repair by a single surgeon, and had cuff integrity assessed by ultrasound 6 months after operation.ResultsRetear rates ranged from 3% to 34%, with a mean of 15%. Over our study retear rates decreased from 18% to 5%. Reductions in retear rates were associated with less aggressive rehabilitation, postoperative abduction sling use, and increased surgical experience. Increases in retear rates were associated with increased false positives with a more sensitive ultrasound machine and learning curves with new equipment for a surgeon and sonographer.ConclusionA decrease in retear rate after arthroscopic rotator cuff repair occurred during our study. Although the study design prevents us from directly attributing changes in retear rate to changes in management, our results suggest that rehabilitation optimization and increased surgeon experience decrease postoperative retear.

The Learning Curve of the Direct Anterior Approach without Traction Table in Total Hip Replacement: Using the LC-CUSUM Method

AbstractThe surgical approach for total hip replacement (THR) depends on surgeon preference or the preference and experience of the surgeon with a specific approach. The aim of this study was to analyze the learning curve of the direct anterior approach (DAA) using the cumulative summation test for learning curve (LC-CUSUM). A retrospectively collected database of 400 THRs using the DAA (January 2010–September 2014) at a single center by a single surgeon. The learning curve was analyzed by determining the duration of surgery, blood loss, and number of complications. All 400 primary THRs were reviewed. Based on the LC-CUSUM, duration of surgery, and surgical failure, the learning curve plateau was achieved after the 19th surgery and the curve follows a substantially negative trend. The average duration of surgery changed significantly for the first hundred (78 minutes) to the last hundred (61 minutes). A significant decrease in blood loss was observed as well. A total of 17 (4.25%) complications occurred, with reduction of the complication rate as surgeons' experience increases. The authors' study did not show the long learning curve as previously described in the literature. The number of complications was small, and there was a significant decrease in duration of surgery, blood loss, and number of complications as surgeon's experience increases. The authors suggest that the educational environment of a teaching hospital, combined with the use of the DAA as a standard approach for all primary THRs and supervision of experienced surgeons, contribute to the favorable learning curve with a low complication rate.

Initial learning curve for robot-assisted partial nephrectomy performed by a single experienced robotic surgeon.

The objective of this study was to evaluate the initial learning curve for robot-assisted partial nephrectomy (RAPN) using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, California). This study included the initial 65 consecutive patients with small renal tumors who had undergone RAPN at our institution. A single trained surgeon with extensive experience in robot-assisted radical prostatectomy, but not in laparoscopic partial nephrectomy, performed RAPN for all patients using the da Vinci Xi. The learning curve was analyzed by examining the perioperative outcomes among five groups each consisting of 13 consecutive patients. In this series, the median tumor size and R.E.N.A.L. nephrometry score were 23 mm and 7, respectively, and the median console time and warm ischemia time (WIT) were 116 and 15 minutes, respectively. Fifty-eight patients (89.2%) achieved trifecta outcomes, meaning that the ischemic time was ≤25 minutes, there was a negative surgical margin, and no major postoperative complications occurred. Although there were no significant changes in R.E.N.A.L. nephrometry scores over time, increased surgeon experience was significantly associated with a shorter console time and WIT. Drawing logarithmic approximation curves enabled the achievement of a console time ≤150 minutes and WIT ≤20 minutes at the sixth and fourth procedures, respectively. Furthermore, multivariate analysis identified an independent correlation between surgeon experience with WIT, but not with console time. These findings suggest that regardless of a surgeon's prior experience in laparoscopic partial nephrectomy, an experienced robotic surgeon can perform RAPN using the da Vinci Xi with acceptable perioperative outcomes after a small number of procedures.

Adipose-only sentinel lymph nodes: a finding during the adaptation of a sentinel lymph node mapping algorithm with indocyanine green in women with endometrial cancer.

To identify factors that affect successful adaptation of sentinel lymph node mapping and those that lead to unintended adipose-only sentinel lymph node identification. Surgical and pathological data were prospectively collected on patients with endometrial cancer who underwent sentinel lymph node mapping with indocyanine green with or without pelvic and/or para-aortic lymph node dissection between November 2013 and April 2017. All mapping cases were performed with the robotic system. Adipose-only specimens were defined as a sentinel lymph node without a pathologically identified lymph node after ultrastaging. A total of 202 patients were included: 83% had endometrioid pathology, 12% serous, 3% carcinosarcoma, and 2% clear cell, with mixed pathology noted in 2%. The bilateral sentinel lymph node detection rate was 66%, and the rate of mapping at least a unilateral sentinel lymph node was 86%. Neither the bilateral nor the unilateral sentinel lymph node mapping rate changed with increased surgeon experience. The rate of adipose-only sentinel lymph node identification was more frequent when comparing the first 10 cases (37%), cases 11 - 30 (28%), and > 30 cases (9%) (P = 0.006). Body mass index > 30 kg/m2, uterine fibroids, The International Federation of Gynecology and Obstetrics (FIGO) grade, and histology were not found to have a statistically significant impact on either sentinel lymph node identification or adipose-only sentinel lymph node identification. Adipose-only sentinel lymph nodes were more likely with increased time from cervical injection to identification of the sentinel lymph node in the right hemipelvis. The median range was 28 min (14-73) for true sentinel lymph node identification vs 33 min (23-74) for adipose-only sentinel lymph node identification (P = 0.02). Patient and surgeon factors did not impact the identification of sentinel lymph nodes over time. Adipose-only sentinel lymph nodes were more frequently identified in the initial cases and represent a potential complication to adapting sentinel lymph node biopsy without lymphadenectomy. The increase in adipose-only sentinel lymph node identification that was associated with time from cervical injection may represent delayed or disrupted uptake of indocyanine green.

Robotic Fundoplication for Gastroesophageal Reflux Disease and Hiatal Hernia: Initial Experience and Outcome

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common clinical presentation. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery. Between March 2014 and August 2016, 50 patients (18 males and 32 females) underwent robotic fundoplication (17 sliding and 33 paraesophageal hernias). The mean age of the patients was 58 years. Biosynthetic mesh was used in 28 patients with paraesophageal hernia. The mean operative time was 115 minutes (90-132) in the sliding hiatal hernia group, whereas it was 200 minutes (180-210) in the paraesophageal hiatal hernia group. The mean hospital stay was 36 hours (24-96). Eight patients experienced mild dysphagia which resolved after four weeks. No postoperative dysphagia was recorded at 30-month median follow-up. We experienced one recurrence in the sliding hernia group and two recurrences in the paraesophageal hernia group, with two patients treated robotically. Robotic fundoplication in treating sliding hiatal hernia is feasible and safe but is more challenging in the large paraesophageal group. Improved patient outcomes hinge on the operative technique used and increasing surgeon experience. The increased dexterity that robotic surgery affords enables the esophageal surgeon to more adeptly apply the traditional principles of laparoscopic fundoplication.

A comparison of outcomes of four ports versus three ports laparoscopic cholecystectomy

Background: Conventional laparoscopic cholecystectomy is performed using four ports. With increasing surgeon experience, there is a trend towards performing it using three ports. The aim of this study was to compare the three-port laparoscopic cholecystectomy with the conventional four-port technique in terms of safety, benefits and feasibility in a teaching hospital and private hospital setups.Materials &amp; Methods: A retrospective review of medical records was performed on patients who underwent laparoscopic cholecystectomy at KIST Medical College and Teaching Hospital and Om Hospital &amp; Research Center P. Ltd by a single laparoscopic surgeon. The review included demographics, operating time, analgesics requirement, post- operative hospital stay and intra-operative and post-operative complications. The data were tabulated in MS-Excel and statistically analyzed using SPSS statistics software, version 21.Results: There were 150 patients included in this study with 75 patients in each three and four-port groups. The demographics were comparable in both groups. 7.3% were diagnosed with acute calculous cholecystitis, 76.7% with chronic calculous cholecystitis and 3.3 % were gall bladder polyps. Four-port technique was generally required for the acute calculous cholecystitis which was statistically significant. The three-port group had a shorter mean operative time than the four-port group. There was no statistically significant difference in the doses of analgesics requirement and mean post-operative hospital stay in both groups. There were no major intra and post-operative complications in both groups. Four-port technique was commonly done in teaching hospital and the three-port in private hospital.Conclusions: There is significant number of laparoscopic cases being performed using three ports and we concluded that the three-port laparoscopic cholecystectomy is safe and feasible in experienced hand although there is no significant benefit. The study also showed an increasing use of four-port technique in the teaching institution which is better to clearly visualize the anatomy of the Calot’s triangle. So we recommend using the four-port technique for teaching the beginners and as the experience is gained, we can gradually shift to three-port technique and at the same time we shouldn’t hesitate to convert to four-port in difficult cases.JMMIHS.2018;4(1):66-71

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives.

Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.

Minimal invasive approach for beyond total mesorectal excision/extended resections in rectal cancer

Minimal invasive surgery (MIS) is an accepted modality of treatment for rectal cancer. The indications for MIS have gradually been extended to locally advanced and locally recurrent rectal cancer as a result of technological advances in instrumentation, advances in surgical techniques, increased surgeon experience, and high volume center. However, safety and feasibility of laparoscopic surgery and robotic surgery in beyond total mesorectal excision (b-TME) and extended TME (e-TME) are not well established. This review summarizes the current evidence for MIS approach for b-TME/extended resections in rectal cancer. A systematic search was carried out in PubMed. Studies available in English related to MIS approach in b-TME/e-TME in rectal cancers were identified and evaluated. This review concludes MIS is feasible with good perioperative outcomes in b-TME/e-TME in carefully selected patients. Laparoscopic surgery has considerable learning curve and should be performed by experienced surgical teams. Robotic surgery is feasible and beneficial in complex resection in pelvis. However, evidence for long-term oncological outcomes of MIS in b-TME/e-TME is low and needs to be studied further by randomized controlled trial once enough numbers are possible in institutes with high volume rate.