Supervision Of Experienced Surgeon Research Articles

Simulation in pediatric minimally invasive surgery: adaptation of a simple series of exercises as part of the process of an initial implementation of a resident training program.

the simulation in minimally invasive surgery is fundamental for surgeon in training to learning and training skills, especially in pediatrics, due to the particularities, reduced spaces, specific and rare procedures. The aim of this study was to propose an adapted series of exercises and to simply evaluate the performance of pediatric surgery residents in the initial implementation of a training program. seven basic skills exercises in video surgery, based on series and programs already published and using low-cost materials, were performed by six residents in 2 moments, with an interval of 15 days and evaluated by simple instrument. there was no difficulty with models. Considering the individual averages of the seven exercises together in the two moments, five of the six residents increased the score in the second moment. The average score per exercise increased in five of the seven tasks. Despite the small number of participants and repetition, it has already been possible to observe a trend of better performance with decreased time of all residents after a single repetition. All considered the exercises capable of training essential skills of the specialty, with simple and inexpensive materials. given the challenges of simulated training in pediatric video surgery, it is known the benefit of a continuous program, with exercises that can simulate real situations. A pre-established schedule, more participants and repetitions, supervision of experienced surgeons and validated instruments are fundamental to evaluate surgeons in training and show statistical benefits of simulated exercises in this series.

Enhanced Recovery after Surgery Applied to Pediatric Laparoscopic Cholecystectomy for Simple Cholelithiasis: Feasibility and Teaching Insights.

Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients. In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees. Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9-18), and the median duration of surgery was 54 min (IQR 13-145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified. These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons. Level III.

Visual and Refractive Outcomes Following SMILE to Correct Myopia Performed by Surgeons in Training.

To assess visual outcomes and complications following small incision lenticule extraction (SMILE) performed by cornea fellows under the supervision of experienced surgeons. This retrospective, noncomparative case series was designed to assess outcomes following SMILE procedures performed at a large surgical center by cornea fellows between May 1, 2012 and March 30, 2015. Preoperative and postoperative uncorrected distance visual acuity (UDVA), preoperative and postoperative corrected distance visual acuity (CDVA), spherical equivalent (SE) up to -10.00 diopters (D), and complications were recorded. A total of 114 patients (228 eyes) met the inclusion criteria. The mean preoperative SE was -5.79 ± 1.95 D (range: -1.75 to -10.00 D) and the mean cylinder was -2.21 ± 1.43 D (range: 0.00 to -5.50 D). At the last follow-up visit (average: 6.4 months), 94% of the patients achieved a UDVA of 20/30 or better and 96% of the patients achieved stability in their vision. Adverse events were encountered in 40 eyes (17.5%), with epithelial defect being the most common. Two patients required a second intervention to improve visual outcomes. SMILE performed by cornea fellows under the supervision of an experienced surgeon is an effective and safe refractive procedure with a short learning curve and excellent visual outcomes. [J Refract Surg. 2022;38(1):28-34.].

The learning curve in proximal hypospadias repair

Although the learning curve in various surgical procedures is increasingly discussed, there have been only a few reports about the learning curve especially in proximal hypospadias repair. To evaluate the learning curve in one-stage hypospadias repair for proximal hypospadias. We retrospectively reviewed 73 cases of primary hypospadias repair by a single pediatric urologist using one-stage urethroplasty with a preputial skin graft between 2007 and 2018. The overall complication rate included fistula, glans dehiscence, and meatal stenosis. To analyze the impact of the surgeon's experience on the complication rate, we compared the complication rates among different groups of 20 consecutive cases each. In addition, we graphed the actual data of the operative time and cumulative complication rate to evaluate the learning curve. The cumulative complication rate was defined as the surgeon's complication rate (the number of complications accumulated at a time/number of cases at that time). The median age at surgery was 18 months (range: 7-87). The median follow-up was 40 months (range: 3-114). In total, 13 (18%) children had complications: 9 fistulae, 3 glans dehiscence, and 2 metal stenoses. The analysis of each 20 cases revealed that the complication rate declined over time as the surgeon became more experienced. It was mainly attributed to a decline of the fistula rate. The diagram of the operative time showed a reduction with the increasing surgical experience. Additionally, the diagram of the cumulative complication rate demonstrated a plateau after 50 cases. Our study showed the positive impact of surgeon experience on the outcome of one-stage repair for proximal hypospadias. In addition, the learning curve in proximal hypospadias repair stabilized after about 50 cases although the supervision of experienced surgeons is required during the early phase of learning curve.

Single-incision laparoscopic appendectomy is a safe procedure for beginners to perform: experience from 1948 cases.

Single-incision laparoscopic appendectomy (SIL-A) has recently become an option for treating appendicitis. The aim of this study was to evaluate the safety, feasibility, and surgical outcomes of SIL-A by residents and surgeons during the learning period. A total of 1948 consecutive patients who underwent SIL-A from May 2008 to November 2014 were studied retrospectively. Surgeries were performed by residents and eight surgeons. Prior to the first case, surgeons and residents had been trained in a training protocol during the learning period. Three initial cases of SIL-A were performed under the supervision of experienced surgeons. Patients were divided into two groups: group 1 (learning period, n = 483), the first 40 cases by each surgeon and resident; and group 2 (experienced period, n = 1465), cases after the 40th procedure performed by each surgeon. Surgical results were compared between the two groups by performing propensity score matching analysis. After propensity score matching, there was no significant difference in patient demographics and characteristics of appendicitis between the two groups. The operating time was longer in group 1 than in group 2 (45.3 ± 18.0 vs. 33.9 ± 16.1min, p < 0.001). The morbidity rate (7.0% vs. 6.5%, p = 0.795) was similar between the two groups. Readmission rate (2.1% vs. 1.3%, p = 0.414) and reoperation rate (0.8% vs. 0.8%, p = 0.348) were also similar between the two groups. However, the rate of incisional hernia occurrence (0.6% vs. 0%, p = 0.066) tended to be larger in group 1 than in group 2 without showing a significant difference. SIL-A is a technically feasible and safe procedure when it is performed by residents and surgeons during learning period under an appropriate training protocol. However, residents and surgeons in the learning period should perform it carefully to prevent incisional hernias.

Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review.

The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15-20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.

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.

Thoracoscopic Esophageal Atresia Repair in Pakistan: Early Learning Curve

Background: Esophageal atresia is rare congenital anomaly, which is traditionally repaired by open thoracotomy. Thoracoscopic esophageal atresia repair has evolved as an effective and safe technique.Material and Methods: This is a retrospective review of 11 cases of esophageal atresia (type C), between June 2015 to May 2016. The objective of study is to describe our initial learning curve of thoracoscopic esophageal atresia repair.Results: Out of 11 patients, initial 4 underwent video assisted technique through single incision of 2 cm to visualize the exact video-scopic anatomy and to do few steps if possible. In last 7 cases, steps were completed with both ends mobilization and intracorporeally single layer interrupted stitching of esophagus. Complications encountered in 3 patients like esophageal leak in one managed conservatively, stenosis and reflux in one patient each.Conclusion: Thoracoscopic esophageal atresia repair is challenging and demanding surgery. Every surgeon has a learning curve before successful thoracoscopic repair which requires skills and learning under supervision of experienced surgeons.

Impact of Surgeon Experience During Carotid Endarterectomy Operation and Effects on Perioperative Outcomes.

ObjectiveWe evaluated the effect of surgeon experience on complication and mortality rates of carotid endarterectomy operation.MethodsFifty-nine consecutive patients who underwent carotid endarterectomy between January 2013 and February 2016 were divided into two groups. Patients who had been operated by surgeons performing carotid endarterectomy for more than 10 years were allocated to group 1 (experienced surgeons; n=34). Group 2 (younger surgeons; n=25) consisted of patients operated by surgeons independently performing carotid endarterectomy for less than 2 years. Both groups were compared in respect of operative results and postoperative complications.ResultsNo intergroup difference was found for laterality of the lesion or concomitant coronary artery disease. In group 1, signs of local nerve damage (n=2; 5.9%) were detected, whereas in group 2 no evidence of local nerve damage was observed. Surgeons in group 1 used local and general anesthesia in 3 (8.8%) and 31 (91.2%) patients, respectively, while surgeons in group 2 preferred to use local and general anesthesia in 1 (4%) and 24 (96%) patients, respectively. Postoperative stroke was observed in group 1 (n=2; 5.9%) and group 2 (n=2; 5.8%).ConclusionYounger surgeons perform carotid endarterectomy with similar techniques and have similar results compared to experienced surgeons. Younger surgeons rarely prefer using shunt during carotid endarterectomy. The experience and the skills gained by these surgeons during their training, under the supervision of experienced surgeons, will enable them to perform successful carotid endarterectomy operations independently after completion of their training period.

Evaluation of Functional Outcomes after Stapes Surgery in Patients with Clinical Otosclerosis in a Teaching Institution.

Introduction Otosclerosis is a primary disease of the temporal bone that leads to stapes ankylosis. Hearing loss is the main symptom. Treatment includes surgery, medical treatment, and sound amplification therapy alone or in combination. Objective To evaluate the functional outcomes of patients with clinical diagnosis of otosclerosis undergoing primary stapes surgery in a teaching institution. Method Retrospective descriptive study. Results A total of 210 ears of 163 patients underwent stapes surgery. Of the 163 patients, 116 (71.2%) underwent unilateral surgery and 47 (28.8%) underwent bilateral surgery. Six of the 210 operated ears had obliterative otosclerosis. The average preoperative and postoperative air–bone gap was 32.06 and 4.39 dB, respectively. The mean preoperative and postoperative bone conduction threshold was 23.17 and 19.82 dB, respectively. A total of 184 (87.6%) ears had a residual air–bone gap <10 dB, and 196 (93.3%) had a residual air–bone gap ≤15 dB. Two patients (0.95%) had severe sensorineural hearing loss. Conclusion Stapes surgery showed excellent functional hearing outcomes in this study. This surgery may be performed in educational institutions with the supervision of experienced surgeons.

Visual Force Feedback Improves Knot-Tying Security

Residents in surgical specialties suture multiple wounds in their daily routine and are expected to be able to perform simple sutures without supervision of experienced surgeons. To learn basic suture skills such as needle insertion and knot tying, applying an appropriate magnitude of force in the desired direction is essential. To investigate if training with real-time visual force feedback improves the suture skills of novices, a study was conducted using a training platform that measures all forces exerted on a skin pad, i.e., the ForceTRAP. Two groups of novices were trained on this training platform during a suture task. One group (nov-c) received no visual force feedback during training, whereas the test group (nov-t) trained with visual feedback. The posttest and follow-up test were performed without visual force feedback. A significant difference in reaction force, (nov-c: mean 2.47N standard deviation [SD] ± 0.62, nov-t: mean 1.79N SD ± 0.37), suture strength (nov-c: median 25N interquartile range (IQR) 15, nov-t: median 50N interquartile range 25), and task time (nov-c: mean 109s SD ± 22, nov-t: mean 134s SD ± 31) was found between the control and training group of the posttest. Participants that are trained with visual force feedback produce the most secure knots in the posttest and their suturing results in lower applied forces. Therefore, the results of this study indicate that visual force feedback supports students while learning to insert the needle smoothly, to effectively align the suture threads and to balance the force between instruments during knot tying. However, for long-term learning effects, probably more than 1 training session is required.

Initial experience of a surgical fellow in laparoscopic colorectal cancer surgery under training protocol and supervision: comparison of short-term results for 70 early cases (under supervision) and 73 late cases (without supervision)

Laparoscopic colorectal surgery is a technically challenging procedure for beginners, such as surgical fellows. The purpose of this study was to assess the safety, feasibility, and short-term surgical outcomes of laparoscopic colorectal cancer surgery by a single surgical fellow. The study analyzed the data from 143 consecutive patients who underwent laparoscopic colorectal resection by a single surgical fellow between August 2009 and October 2010. The patients were divided into two groups: the early group-the first 70 patients (under supervision of experienced surgeon), and the late group-the last 73 patients (without supervision). The short-term surgical results were compared between two groups. The operations were 24 right colon resections, two transverse colectomies, six left colectomies, 36 anterior resections, 57 low anterior resections, 12 intersphincteric resections, two abdominoperineal resections, three Hartmann's operations, and 1 total colectomy. The mean operating time, mean amounts of blood loss, and conversion rate were similar between the two groups. The morbidity rate, anastomosis leak rate, and mortality rate within 30 days of surgery did not differ significantly. The mean number of lymph nodes was larger in the late group (23.8 vs. 31.7, P = 0.017). In terms of low anterior resection, the mean number of endo-linear staplers used was smaller in the late group (2.46 ± 0.81 vs. 1.97 ± 0.83, P = 0.028). The anastomosis leakage rate in rectal cancer surgery was not significantly different between the two groups. This study demonstrates that laparoscopic colorectal resections can be independently performed safely after a period of supervision and training by an experienced surgeon.

Role of Appendectomy in Laparoscopic Training

This study aimed to evaluate whether laparoscopic appendectomy is suitable for training residents to become proficient in laparoscopic surgery. A total of 1574 laparoscopic appendectomies were performed at En-Chu-Kong Hospital between January 1998 and December 2003 (788 men and 786 women). These cases were divided into three groups: 543 cases (in 1998-1999) performed by 5 attending surgeons during the learning and trial stage; 536 cases (in 2000-2001) performed by 5 attending surgeons assisted by 2 senior residents with prior experience in open appendectomy; and 495 cases (in 2002-2003) done by these 2 senior residents, supervised by the attending surgeons. Demographic data, intraoperative findings, operative time, conversion rate, frequency of analgesic injection, timing of oral intake, hospital stay, morbidity, and mortality were analyzed. There were no statistically significant differences in the operations performed by attending surgeons (mature stage) vs. senior residents in terms of intraoperative findings, operative time (60.1 +/- 60.4 minutes vs. 56.3 +/- 25.6 minutes), conversion rate (1.12% vs. 0.81%), frequency of analgesic injection (0.57 +/- 1.37 times/stay vs. 0.43 +/- 0.94 times/stay), timing of oral intake (23.7 +/- 30.2 hours vs. 20.8 +/- 27.5 hours), hospital stay (73.9 +/- 61.8 hours vs. 70.3 +/- 51.6 hours), morbidity, or mortality (0% vs. 0.2%). Laparoscopic appendectomy can be safely incorporated into the training of surgical residents under the supervision of experienced surgeons. Laparoscopic appendectomy also provides knowledge of the basics of laparoscopic technique before going on to more complex operations.

Is D2 Lymphadenectomy in Gastrectomy Safe with Regard to the Skill of the Operator?

Background/Aims: D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival benefit in the West. Recent western studies, however, especially from specialist centers, have shown a survival benefit and the safety of D2 gastrectomy. The aim of this study is to clarify the safety of D2 gastrectomy (defined by the Japanese Research Society for the Study of Gastric Cancer), even if carried out by a junior surgeon, and to show that it is not a particularly difficult or special procedure. Methods: Patients who underwent a typical distal gastrectomy (DG) with D2 resection (n = 344) and total gastrectomy (TG) with D2 resection (n = 111) were analyzed. The subjects were divided into 3 groups according to the postgraduate year of the operator (group I = the surgeon’s postgraduate experience was less than 5 years; group II = surgeons with more than 5 years and less than 10 years postgraduate experience; group III = surgeons with more than 10 years postgraduate experience). The rate of postoperative complications and the 5-year survival rate were compared among the 3 groups. Results: The overall operative mortality rate, hospital death rate and the overall rate of postoperative complications were 1.2, 2.0 and 10.2% in DG patients, and 14.4, 0 and 1.8% in TG patients, respectively. There was no significant difference in the operative blood loss, the rate of operative mortality, hospital death rate and postoperative complications among the 3 groups. There was no significant difference in the 5-year survival rate among the 3 groups in each stage. Conclusion: The postoperative mortality rate, morbidity rate and 5-year survival rate after a typical D2 gastrectomy were independent of the experience of the operator. It is considered to be a safe and useful procedure in view of the rate of postoperative complications and the long-term survival rate, even if performed by a junior trainee under the supervision of experienced surgeons in a nonspecialized hospital.

Cataract Surgery With Intraocular Lens Implantation by Ophthalmology Resident Surgeons

Cataract surgery with intraocular lens implantation (cataract-IOL surgery) performed by ophthalmology residents under supervision of experienced surgeons in 1974-1978 was analyzed. Retrospective evaluation of 32 cases noted patient age and sex distribution, preoperative ophthalmic examination findings, technique for cataract surgery with implantation of iris support intraocular lenses, postoperative complications, and visual acuity with best correction 30 months after surgery as well as on the last examination. Postoperative follow-up, ranging from one to 84 months, recorded a visual acuity with best correction of 20/40 or better in 87.5% of cases. Excluding two cases in which decreased visual acuity resulted from macular degeneration, visual acuity with best correction was 20/40 or better in 94% of cases.