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1
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Cariati M, Brisinda G, Chiarello MM. Has the open surgical approach in colorectal cancer really become uncommon? World J Gastrointest Surg 2024; 16:1485-1492. [PMID: 38983350 PMCID: PMC11230011 DOI: 10.4240/wjgs.v16.i6.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 06/27/2024] Open
Abstract
Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Giuseppe Brisinda
- Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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2
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Talavera-Urquijo E, Gantxegi A, Garbarino GM, Capovilla G, van Boxel GI, Grimminger PP, Luyer MD, Markar SR, Svendsen LB, van Hillegersberg R. ESDE-MIE fellowship: a descriptive analysis of the first experiences. Dis Esophagus 2023; 36:doac112. [PMID: 36688901 DOI: 10.1093/dote/doac112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 01/24/2023]
Abstract
Esophageal resection is a high-risk and technically demanding procedure, with a long proficiency-gain curve. The European Society Diseases of the Esophagus (ESDE)-Minimally Invasive Esophagectomy (MIE) training program was launched in 2018 for European surgeons willing to train and to begin a career undertaking MIE. The aim of this study was to evaluate the first experience of the ESDE-MIE fellowship and relate this to the initially predetermined core principles and objectives of the program. Between October 2021 and May 2022, the participating fellows, in collaboration with the ESDE Educational Committee, initiated a survey to assess the outcome and experience of these fellowships. Data from each individual fellowship were analysed and reported in a descriptive manner. Between 2018 and 2022, in total, five fellows have completed the ESDE-MIE fellowship program. Despite the COVID-19 outbreak just the year after its launch, predetermined clinical and research goals were achieved in all cases. Each of the fellows were able to assist in a median of 40 (IQR 27-69) MIE and/or Robot assisted (RA)MIE procedures, of a total median of 115 (IQR 83-123) attended Upper GI cases. After the fellowship, MIE has been fully adopted by the fellows who returned to their home institutions as Upper GI surgeons. The fellowship was concluded by the European Union of Medical Specialists (UEMS) Multidisciplinary Joint Committee (MJC) certification in Upper GI Surgery, which was successfully obtained by all who took part. Based on the experience of the first five fellows, the ESDE-MIE training fellowship meets with the expected needs even despite the COVID-19 outbreak in 2019. Furthermore, these fellows have returned home and integrated MIE into their independent surgical practice, affirming the ability of this program to train the next generation of MIE surgeons, even in the most challenging of circumstances.
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Affiliation(s)
| | - Amaia Gantxegi
- Department of Surgery, Vall d´Hebron Hospital Universitari, Barcelona, Spain
| | - Giovanni M Garbarino
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Gastrointestinal Surgery Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Gijs I van Boxel
- Department of Upper GI Surgery, Portsmouth Hospitals University, Portsmouth, UK
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Sheraz R Markar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Lars B Svendsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
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3
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Adachi T, Kitaguchi D, Teramura K, Hasegawa H, Ikeda K, Tsukada Y, Nishizawa Y, Sasaki T, Ito M. Single-center comparative study of short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. Surg Endosc 2023:10.1007/s00464-023-09948-1. [PMID: 36890411 DOI: 10.1007/s00464-023-09948-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. METHODS This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10 cm) or low (< 5 cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1 mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared. RESULTS Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%. CONCLUSIONS Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.
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Affiliation(s)
- Toshiyuki Adachi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koichi Teramura
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Boualila L, Souadka A, Benslimane Z, Amrani L, Benkabbou A, Raouf M, Majbar MA. Comparison of Short-Term and Long-Term outcomes of Laparoscopy Versus Laparotomy in Rectal Cancer: Systematic Review and Meta-analysis of Randomized Controlled Trials. JOURNAL OF MEDICAL AND SURGICAL RESEARCH 2021. [DOI: 10.46327/msrjg.1.000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and objective: The last randomized controlled trials ,the ACOSOG Z6051 1,2 and the ALaCaRT trial3, 4 could not show the non-inferiority of the laparoscopy in comparison to laparotomy for rectal cancer. In fact, the ten first years of practicing laparoscopy were years when surgeons developed their learning curve. Therefore, by excluding this learning bias, it is possible to end up with a more fair and correct comparison between the two techniques. It is henceforth relevant to pursue a new meta-analysis that compares the two techniques and excludes studies done during the earlier periods of laparoscopic rectal surgery. Results: Six randomized controlled trials met the eligibility criteria, involving a total of 1556 patients in the laparoscopy group and 1188 patients in the laparotomy group. Our meta-analysis was in favor of laparoscopy in a significant way for blood loss, first bowel movement and the number of harvested lymph nodes. It was non-significantly in favour of laparoscopy for 30-days mortality after surgery and length of hospital stay. It was significantly in favor of laparotomy for operative duration. No significant difference was found in anastomotic leakage) , reoperation within 30 days, number of positive CRMs and completeness of mesorectal excision between the two groups. No difference was found in recurrence, disease-free survival and overall survival between laparoscopy group and laparotomy group. Conclusion: The comparison of the randomized controlled trials published before and after 2010, showed no significant difference in outcomes between the learning period and after.
Keywords: Laparoscopy, laparotomy, long-term outcomes, meta-analysis, short-term outcomes, rectal cancer
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SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 2020; 34:2327-2331. [PMID: 32323016 PMCID: PMC7175828 DOI: 10.1007/s00464-020-07565-w] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.
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van Workum F, Fransen L, Luyer MDP, Rosman C. Learning curves in minimally invasive esophagectomy. World J Gastroenterol 2018; 24:4974-4978. [PMID: 30510372 PMCID: PMC6262255 DOI: 10.3748/wjg.v24.i44.4974] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/28/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023] Open
Abstract
Surgical innovation and pioneering are important for improving patient outcome, but can be associated with learning curves. Although learning curves in surgery are a recognized problem, the impact of surgical learning curves is increasing, due to increasing complexity of innovative surgical procedures, the rapid rate at which new interventions are implemented and a decrease in relative effectiveness of new interventions compared to old interventions. For minimally invasive esophagectomy (MIE), there is now robust evidence that implementation can lead to significant learning associated morbidity (morbidity during a learning curve, that could have been avoided if patients were operated by surgeons that have completed the learning curve). This article provides an overview of the evidence of the impact of learning curves after implementation of MIE. In addition, caveats for implementation and available evidence regarding factors that are important for safe implementation and safe pioneering of MIE are discussed.
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Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen 6500 HB, Netherlands
| | - Laura Fransen
- Department of Surgery, Catharina Hospital, Eindhoven 5602 ZA, Netherlands
| | - Misha DP Luyer
- Department of Surgery, Catharina Hospital, Eindhoven 5602 ZA, Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen 6500 HB, Netherlands
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7
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Visser E, van Rossum PSN, van Veer H, Al-Naimi K, Chaudry MA, Cuesta MA, Gisbertz SS, Gutschow CA, Hölscher AH, Luyer MDP, Mariette C, Moorthy K, Nieuwenhuijzen GAP, Nilsson M, Räsänen JV, Schneider PM, Schröder W, Cheong E, van Hillegersberg R. A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe. Dis Esophagus 2018; 31:4601761. [PMID: 29121243 DOI: 10.1093/dote/dox124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.
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Affiliation(s)
| | - P S N van Rossum
- Departments of Surgery
- Radiation Oncology, University Medical Center Utrecht, Utrecht
| | - H van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital NHS Foundation Trust
| | - M A Cuesta
- Department of Gastrointestinal Surgery, VU University Medical Center
| | - S S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam
| | - C A Gutschow
- Department of Visceral and Transplantation Surgery, University Hospital Zurich
| | - A H Hölscher
- Department of Surgery, Center for Esophageal and Gastric Surgery, and Frankfurt
| | - M D P Luyer
- Department of Surgery, Catherina Hospital Eindhoven, Eindhoven, The Netherlands
| | - C Mariette
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - K Moorthy
- Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, United Kingdom
| | | | - M Nilsson
- Department of Surgery, Karolinski University Hospital
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - J V Räsänen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - P M Schneider
- Department of Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - E Cheong
- General Surgery, Norfolk and Norwich University Hospital, Norwich
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8
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Penna M, Whiteford M, Hompes R, Sylla P. Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA. Colorectal Dis 2017; 19:476-484. [PMID: 27647728 DOI: 10.1111/codi.13525] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 07/25/2016] [Indexed: 02/08/2023]
Abstract
AIM Transanal total mesorectal excision (taTME) has become one of the most promising technical advancements in the surgical treatment of rectal cancer, with rising numbers of surgeons seeking training. We describe our experience with human cadaveric courses for taTME delivered in two countries. METHOD Four fresh human cadaveric workshops conducted in Oxford, UK, in 2015 and two in Chicago, USA, in 2013-2014, trained a total of 52 surgeons. Parameters of operative performance for each delegate were recorded. Previous surgical experience and uptake of taTME in the surgeons' clinical setting were surveyed. RESULTS Forty-seven taTME cases were performed on cadaveric models. Participating surgeons had previous experience in laparoscopic TME surgery and transanal approaches but limited taTME exposure. The purse-string remained occluded throughout in 93% of UK and 60% of US cases. Operative timings for key procedural steps were similar between the two countries with a mean time from start of circumferential dissection to peritoneal entry of 79.5 min (range 25-155). 96% of surgeons dissected transanally to a level S2 or above. The TME specimen quality was complete or near complete in 81%, with improvements noted between the first and second procedure performed. 81% of surgeons surveyed are currently performing taTME in their local hospitals. CONCLUSION Fresh-frozen cadavers provide excellent teaching models for complex pelvic surgery. A structured training curriculum including reading material, dry-lab purse-string practice and postcourse mentorship will provide surgeons with a more complete training package and ongoing support, to ultimately ensure the safe introduction of taTME in the clinical setting.
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Affiliation(s)
- M Penna
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - M Whiteford
- The Oregon Clinic, Providence Cancer Center, Oregon Health and Science University, Portland, OR, USA
| | - R Hompes
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - P Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
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9
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Consensus on structured training curriculum for transanal total mesorectal excision (TaTME). Surg Endosc 2017; 31:2711-2719. [PMID: 28462478 DOI: 10.1007/s00464-017-5562-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 04/01/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME. METHODS A consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert's consensus to draw an agreement on essential elements of the curriculum. RESULTS Appropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and accreditation in laparoscopic colorectal surgery, with prior experience in transanal surgery. Ideally, two surgeons should undergo training together in centres with high volume for rectal cancer surgery. Mentorship and multidisciplinary training were the two most important aspects of the curriculum, which should also include online modules and simulated training for purse-string suturing. Mentors should have performed at least 20 TaTME cases and be experienced in laparoscopic training. Reviewing the specimens' quality, clinical outcome data and entering data into a registry were recommended. Assessment should be an integral part of the curriculum using Global Assessment Scales, as formative assessment to promote learning and competency assessment tool as summative assessment. CONCLUSIONS A detailed framework for a structured TaTME training curriculum has been proposed. It encompasses various training modalities and assessment, as well as having the potential to provide quality control and future research initiatives for this novel technique.
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10
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Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship. Ann Med Surg (Lond) 2017; 13:38-41. [PMID: 28070329 PMCID: PMC5219610 DOI: 10.1016/j.amsu.2016.12.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 12/03/2022] Open
Abstract
Since the first laparoscopic procedure, there has been an steady increase in advanced minimally invasive surgery. These procedures include oncological colorectal, hepatobiliary and upper gastrointestinal surgery. Implementation of these procedures requires different and new skills for the surgeons who wish to perform these procedures. To accomplish this surgical teaching program, a mentorship seems the most ideal method to teach the apprentice surgeon these specific skills. At the VU medical center a teaching program for a minimally-invasive esophagectomy for esophageal cancer started in 2009. At first it started in different centers in the Netherlands and later on we also started mentoring other institutes throughout Europe, Latin America and India. In this article we describe our experience and the outcomes of this mentorship in advanced minimally invasive surgery.
Not all residency programs include a teaching program with the guidance of dedicated mentors. Teaching minimally invasive surgery requires a mentor. A dedicated team should be set up for learning new minimally invasive techniques.
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11
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Beyer-Berjot L, Berdah S, Hashimoto DA, Darzi A, Aggarwal R. A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery. JOURNAL OF SURGICAL EDUCATION 2016; 73:932-941. [PMID: 27342755 DOI: 10.1016/j.jsurg.2016.05.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/13/2016] [Accepted: 05/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy. DESIGN This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis. SETTING Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved. PARTICIPANTS Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons. RESULTS A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence. CONCLUSIONS A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom; Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Stéphane Berdah
- Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ara Darzi
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rajesh Aggarwal
- Arnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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12
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Bosio RM, Pigazzi A. Emerging and Evolving Technology in Colon and Rectal Surgery. Clin Colon Rectal Surg 2015; 28:152-7. [PMID: 26491407 DOI: 10.1055/s-0035-1558823] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Minimally invasive surgery has changed the way we manage many colon and rectal pathologies. Multiple techniques, from straight laparoscopic procedures, to hand-assisted and single-port techniques are available, requiring surgeons to go through various learning curves. Robotic surgery is a relatively novel technique in general surgery which appears to hold most promise for rectal resection. Laparoscopic rectal procedures are difficult, and even in experienced hands, conversion rates are around 17%. Robotic surgery may be a point of difference in these cases, despite a long learning curve and higher costs. This article will describe the role of robotics in colorectal surgery. Room set up, port placement, and docking strategies will be described for common procedures, with emphasis on a hybrid robotic low anterior resection.
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Affiliation(s)
- Raul M Bosio
- Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alessio Pigazzi
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, California
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13
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Beyer-Berjot L, Palter V, Grantcharov T, Aggarwal R. Advanced training in laparoscopic abdominal surgery: a systematic review. Surgery 2014; 156:676-88. [PMID: 24947643 DOI: 10.1016/j.surg.2014.04.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/18/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator. METHODS Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles. RESULTS Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid. CONCLUSION Higher-quality studies are required to appraise educational value in this field.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Center for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Vanessa Palter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Grantcharov
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rajesh Aggarwal
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Dixon M, Mahar A, Paszat L, McLeod R, Law C, Swallow C, Helyer L, Seeveratnam R, Cardoso R, Bekaii-Saab T, Chau I, Church N, Coit D, Crane CH, Earle C, Mansfield P, Marcon N, Miner T, Noh SH, Porter G, Posner MC, Prachand V, Sano T, Van de Velde CJH, Wong S, Coburn N. What provider volumes and characteristics are appropriate for gastric cancer resection? Results of an international RAND/UCLA expert panel. Surgery 2013; 154:1100-9. [PMID: 24075275 DOI: 10.1016/j.surg.2013.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND A relationship between higher volume providers and improved outcomes has been suggested by some studies and has been used to construct guidelines for many diseases. For gastric cancer (GC), however, optimal volume cutoffs are not clear. METHODS A multidisciplinary expert panel of 16 physicians from 6 countries scored 120 scenarios regarding provider characteristics for gastric resections for GC. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed on were scored subsequently for necessity. RESULTS Surgeon and hospital practice volume scenarios were evaluated. The panel felt it was inappropriate for surgeons doing ≤2 GC cases per year to perform a multivisceral resection (MVR), D2 lymphadenectomy (D2-LND), or laparoscopic total gastrectomy, and ≤6 GC cases per year for an MVR involving a pancreatoduodenectomy (MVR-PD), or endoscopic mucosal resections (EMR). It was considered appropriate for surgeons doing ≥11 GC cases per year to perform open gastrectomy or D2-LND, and ≥20 GC cases per year for any MVR, laparoscopic gastrectomy, or EMR. For hospitals, it was considered inappropriate for hospitals managing ≤4 GC cases per year to perform D2-LND or laparoscopic total gastrectomy, and ≤10 GC cases per year, for MVR-PD or EMR. Hospital volumes ≥21 cases per year was considered appropriate for any GC procedure. It was inappropriate for an MVR to be performed in a hospital without interventional radiology services and for a MVR-PD in a hospital with no level I intensive care unit. CONCLUSION Appropriate and inappropriate provider volumes for a variety of gastric procedures have been defined by an international expert panel.
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Affiliation(s)
- Matthew Dixon
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Surgery, Maimonides Medical Center, Brooklyn, NY
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Beyer-Berjot L, Aggarwal R. Toward technology-supported surgical training: the potential of virtual simulators in laparoscopic surgery. Scand J Surg 2013; 102:221-6. [PMID: 24056136 DOI: 10.1177/1457496913496494] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery. MATERIAL AND METHODS This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills. RESULTS AND CONCLUSIONS There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.
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Affiliation(s)
- L Beyer-Berjot
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
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16
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Abstract
OBJECTIVE To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills. BACKGROUND Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear. METHODS We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses. RESULTS Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented. CONCLUSION This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.
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Williams GL, Sagar PM, McAllister I, Gonsalves S. The laparoscopic colorectal fellowships are popular, educational and produce competent laparoscopic surgeons. Colorectal Dis 2009; 11:519-21. [PMID: 19341403 DOI: 10.1111/j.1463-1318.2009.01845.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- G L Williams
- The John Goligher Colorectal Unit, The General Infirmary at Leeds, Leeds, UK
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Abstract
OBJECTIVE Laparoscopic colonic surgery was introduced about 15 years ago and has together with the evidence-based 'fast-track' methodology improved early postoperative outcome. The purpose of this study was to asses the organization and early outcome after laparoscopic colonic surgery in Denmark from 2004 to 2007. METHOD Based upon the National Patient Register, all laparoscopic colonic operations performed in Denmark between January 2004 and December 2006 were analysed regarding number of hospital departments and procedures, hospital stay, readmissions and mortality. RESULTS One thousand one hundred and forty-nine laparoscopic colonic resections without simultaneous stoma formation were performed in the study period. Twenty-five departments performed the procedures but only four departments performed more than 100 procedures. The median length of primary stay was 4 days (mean 7.7 days). One hundred and twenty-five (10.9%) patients were re-admitted within 30 days and total length of stay (primary plus readmissions) was a median of 5 days (mean 8.5 days). Thirty-day mortality was 2.6% and hospital mortality 3.5%. CONCLUSION This nationwide study has shown an increased implementation of laparoscopic colonic surgery but probably performed in too many low volume departments. Laparoscopic colonic surgery should be monitored and further advances secured by adjustment of perioperative care to fast-track care.
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Affiliation(s)
- S Schulze
- Department of Surgical Gastroenterology, Glostrup University Hospital, Glostrup, Denmark.
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Ross HM, Simmang CL, Fleshman JW, Marcello PW. Adoption of laparoscopic colectomy: results and implications of ASCRS hands-on course participation. Surg Innov 2008; 15:179-83. [PMID: 18757376 DOI: 10.1177/1553350608322100] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants. METHODS All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion. RESULTS A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%). CONCLUSIONS Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.
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Affiliation(s)
- Howard M Ross
- Center for Inflammatory Bowel Disease, Riverview Medical Center, Red Bank, New Jersey 07701, USA.
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Valarini R, Campos FGCMD. Resultados do registro nacional brasileiro em vídeo-cirurgia colorretal - 2007. ACTA ACUST UNITED AC 2008. [DOI: 10.1590/s0101-98802008000200001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2025]
Abstract
Este trabalho multicêntrico reúne a experiência de 28 equipes brasileiras em vídeo-cirurgia colorretal. No período de 1992 a 2007 foram operados 5259 pacientes, sendo excluídos 515 (9,8%) doentes devido a dados incompletos. Foram avaliados 4744 pacientes, sendo 1994 homens (41,4%) e 2750 mulheres (58,6%), cuja idade variou de 1 a 94 anos (média de 57,5 anos). Doenças benignas foram diagnosticadas em 2355 pacientes (49,6%). A maioria das afecções (50,7%) localizava-se no cólon esquerdo e sigmóide, 28,2% no reto e 0,3% no canal anal, 8,0% no cólon direito e 7,0% difusa. Ocorreram 29 óbitos (1,6%). Foram operados 2389 (50,4%) pacientes portados de tumores malignos, estando localizados no reto em 48,5%, cólon esquerdo e sigmóide 30,7%, cólon direito 16%, cólon transverso 3,2% e canal anal 0,6%. Os tipos histológicos foram 2347 (98%) adenocarcinomas, 30 (0,6%) carcinomas espinocelulares e outros tipos histológicos em 12 (0,2%) pacientes. A recidiva global foi de 15,3%. Houve 180 (3,8%) complicações intra-operatórias, sendo as mais comuns lesões vasculares de cavidade e lesões de alças intestinais, com incidência de 1%. Foram relatadas 261 (5,5 %) conversões para laparotomia, sendo a causa mais comum a dificuldade técnica em 1,4%. Complicações pós-operatórias foram registradas em 683 (14,5 %). Em período médio de 52 meses de seguimento houve 19 (0,8%) recidivas no local de inserção de trocártes. Não houve recidiva parietal em incisão utilizada para retirada da peça. CONCLUSÕES: 1) Nos últimos anos, a experiência brasileira em vídeo-cirurgia colorretal teve aumento expressivo; 2) As indicações operatórias para câncer e doenças benignas foram semelhantes, sendo que a doença diverticular representou 40 % das doenças benignas tratadas; 3) Os índices de morbi-mortalidade foram baixos e semelhantes aos relatados na literatura; 4) Os resultados oncológicos avaliados demonstram que as ressecções laparoscópicas determinam índices de recidiva parietal semelhantes aos encontrados em operações convencionais.
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Champagne BJ, Lee EC, Valerian B, Armstrong D, Ambroze W, Orangio G. A novel end point to assess a resident's ability to perform hand-assisted versus straight laparoscopy for left colectomy: is there really a difference? J Am Coll Surg 2008; 207:554-9. [PMID: 18926459 DOI: 10.1016/j.jamcollsurg.2008.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/04/2008] [Accepted: 03/05/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND It has been suggested that hand-assisted colectomy (HAC) may help residents progress along the learning curve, but there is currently no evidence to support this claim. Previous studies address procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary end points. We measured the percentage of cases completed by a resident as the operating surgeon as the primary end point to determine the most effective approach for teaching laparoscopic colectomy. STUDY DESIGN All patients who underwent left-sided HAC or straight laparoscopic colectomy (SLC) by a single resident starting as the primary surgeon were included. If the assisting attending physician assumed the role of the operating surgeon during the case, it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end points. RESULTS A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship, including 81 left-sided procedures. There were 44 patients in the HAC group and 37 SLC patients. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC, 88%; HAC, 72%; p=0.06). There were also differences in mean operative time favoring SLC (HAC, 142 minutes [range 100 to 170 minutes] versus SLC, 133 minutes [range 95 to 195 minutes]; p=0.04). Complications were similar in the 2 groups (HAC, 19% versus SLC, 21%), as were conversions (HAC, 5.6% versus SLC, 4.5%). CONCLUSIONS Both hand-assisted and straight laparoscopic techniques for left colectomy can be applied to successfully train surgical residents with the assistance of a staff surgeon outside of their learning curve. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach during training.
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