Intracorporeal anastomosis could be associated with a higher lymph node yield in right colon cancer surgery: Results of the ICA-LATAM study, a retrospective, multicentre, comparative analysis in Latin America.

AIM: The aim of this work was to compare lymph node (LN) yield in patients operated on for right colon cancer (RCC) using a laparoscopic approach between those receiving an intracorporeal (ICA) or extracorporeal anastomosis (ECA). METHOD: This is a retrospective multicentre study involving patients operated on for RCC in nine tertiary referral centres in Latin America during a 2-year period. The main comparative outcome between groups was the number of LNs harvested between groups. RESULTS: The study included 416 patients, 261 (62.7%) in the ECA group and 155 (37.3%) in the ICA group. Patients in the ECA group were elderly (66 vs. 61 years, p < 0.001). Patients receiving an ICA achieved a significantly higher LN yield than those receiving an ECA (24 vs. 18, p < 0.001). This group also had a lower percentage of patients achieving a substandard LN yield (<12 LNs) (10% vs. 24.8%, p = 0.001) and more patients achieving a high number of harvested LNs (>32 LNs) (15.5% vs. 8.3%, p = 0.039). In the multivariate analysis, ICA was independently related to the primary outcome (LN yield) (OR 3.28, p = 0.027, 95% CI 1.14-9.38). CONCLUSION: In this retrospective study, patients operated on for RCC who received an ICA achieved a higher LN yield. Further studies are needed to reconfirm these findings, and also to find an explanation for these results.

An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil.

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

Robotic rectal surgery: Outcomes of the first 102 totally robotic cases handled using the single-docking technique in a reference institution.

BACKGROUND AND OBJECTIVE: Rectal cancer is often surgically treated, but it is still associated with morbidity rates. Minimally invasive techniques are increasingly being used to reduce complications, and the use of such techniques can be found in the literature. This study aims to report our experience in a reference oncology center. METHODS: A retrospective cohort study was performed on a prospective database of patients who underwent robotic surgery for rectal cancer using the single-docking technique from September 2014 to April 2018. Clinical and surgical variables, as well as morbidity and mortality rates, were analyzed. RESULTS: One hundred and two patients underwent robotic surgery. Intraoperative complications occurred in six patients (4.9%), and postoperative complications in 24 patients (23.5%), of which anastomotic fistula represented 3.9%. The conversion rate was 1.96%. Two cases (1.9%) faced death within 30 days. The median length of hospitalization was 3 days. The median number of lymph nodes dissected was 15. Clinical and surgical data were correlated with postoperative complications, and no statistically significant differences were found. CONCLUSION: Robotic surgery is a safe and feasible approach to manage rectal cancer. The method presents satisfactory results with regard to the rate of operative complications, conversion rate, oncologic outcomes, and length of hospitalization.

Safe Introduction of New Technologies and Techniques in Minimally Invasive Colorectal Surgery.

In the past 20 years, colorectal surgery has experienced important advances as a result of new technologies that have increasingly transformed conventional open surgery into maximal usage of minimally invasive approaches. While many tools are being developed to change the way that operations are being performed, quality must not suffer. We describe here some of the aspects to pursue to achieve optimal and safe outcomes while utilizing minimally invasive techniques such as robotic surgery, transanal total mesorectal excision, as well as the role of immunofluorescence.

Stereotactic Pelvic Navigation With Augmented Reality for Transanal Total Mesorectal Excision.

INTRODUCTION: Technical difficulty and unfamiliar surgical anatomy are the main challenges in transanal total mesorectal excision. Precise 3-dimensional real-time image guidance may facilitate the safety, accuracy, and efficiency of transanal total mesorectal excision. TECHNIQUE: A preoperative CT was obtained with 10 skin fiducials and further processed to emphasize the border of the anatomical structure by 3-dimensional modeling and pelvic organ segmentation. A forced sacral tilt by placing a 10-degree wedge under the patient's sacrum was induced to minimize pelvic organ movement caused by lithotomy position. An optical navigation system with cranial software was used. Preoperative CT images were loaded into the navigation system, and patient tracker was mounted onto the iliac bone. Once the patient-to-image paired point registration using skin fiducials was completed, the laparoscopic instrument mounted with instrument tracker was calibrated for instrument tracking. After validating the experimental setup and process of registration by navigating laparoscopic anterior resection, stereotactic navigation for transanal total mesorectal excision was performed in the low rectal neuroendocrine tumor. RESULTS: The fiducial registration error was 1.7 mm. The accuracy of target positioning was sufficient at less than 3 mm (1.8 ± 0.9 mm). Qualitative assessment using a Likert scale was well matched between the 2 observers. Of the 20 scores, 19 were judged as 4 (very good) or 5 (excellent). There was no statistical difference between mean Likert scales of the abdominal or transanal landmarks (4.4 ± 0.5 vs 4.3 ± 1.0, p = 0.965). CONCLUSIONS: Application of an existing navigation system to transanal total mesorectal excision for a low rectal tumor is feasible. The acceptable accuracy of target positioning justifies its clinical use. Further research is needed to prove the clinical need for the procedure and its impact on clinical outcomes.

Synchronous abdominal tumors: is combined laparoscopic surgery in a single approach a safe option?

BACKGROUND AND PURPOSE: Recent advances in cancer treatment have resulted in better prognosis with impact on patient's survival, allowing an increase in incidence of a second primary neoplasm. The development of minimally invasive surgery has provided similar outcomes in comparison to open surgery with potentially less morbidity. Consequently, this technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit. The objective of this study is to describe the experience of two tertiary cancer hospitals in Brazil, in the minimally invasive treatment of synchronous abdominal neoplasms and to evaluate its feasibility and peri-operative results. MATERIALS AND METHODS: We retrospectively reviewed the data from patients who were submitted to combined laparoscopic procedures performed in two tertiary hospitals in Brazil from May 2009 to February 2015. RESULTS: A total of 12 patients (9 males and 3 females) with a mean age of 58.83 years (range: 33 to 76 years) underwent combined laparoscopic surgeries for the treatment of at least one urological disease. The total average duration of surgery was 339.8 minutes (range: 210 to 480 min). The average amount of intraoperative bleeding was 276.6mL (range: 70 to 550mL) and length of hospitalization was 5.08 days (range: 3 to 10 days). Two patients suffered minor complications regarding Clavien system during the immediate postoperative period. CONCLUSIONS: Combined laparoscopic surgery for the treatment of synchronous tumors is feasible, viable and safe. In our study, there was a low risk of postoperative morbidity.

Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESSS): a feasibility study for a new NOTES approach in a swine model.

INTRODUCTION: A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model. MATERIALS AND METHODS: Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the "Holy" plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization. RESULTS: The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach. CONCLUSIONS: Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.

Ten years of IRCAD, Barretos, SP, Brazil.

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Management of postoperative complications during laparoscopic anterior rectal resection.

Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified preoperatively to prevent postoperative complications. In the other hand long term postoperative complications may promote tumor recurrence and decrease survival. The aims of this review are to provide an overview of the current literature on postoperative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.

Overview and perspectives about the robotic surgical certification process in Brazil: the new statement and a national web-survey.

OBJECTIVE: to appraise the general profile of the Brazilian robotic surgeon and the acknowledgment of the new certification process for robotic surgery upon the Associação Médica Brasileira (AMB - Brazilian Medical Association) statement. According to the AMB statement, medical societies and proctors have to achieve leading roles in training and certification of surgeons, acting in partnership with industry. METHODS: a national web-based survey was promoted by the Colégio Brasileiro de Cirurgiões (CBC - Brazilian College of Surgeons) among their members. RESULTS: the 294 answers were split into two groups: 133 (45.3%) who had robotic console certification, and 161 (54.8%) who did not have it. The overall median age was 46, but the non-robotic group presented more surgeons with at least 30 years of experience than to the robotic group (32.3% versus 23.3%, p=0.033). Surgeons with robotic certification more frequently work in a city with at least one million inhabitants than surgeons who were not certified (85.7 versus 63.4%, p<0.001). The majority of surgeons in both groups have similar positioning for all main points of the statement. However, the agreement proportions for the preceptors responsibility during the procedures were higher among non-robotic surgeons that expected the preceptor to assume co-responsibility for the procedure (85% versus 60.9%, p<0.001), and intervene during the procedure as much as necessary (97.5% versus 91.7%, p=0.033). CONCLUSION: the overall agreement of the answers to the AMB statement seems to be a promising pathway to increase the participation of the medical entities into the robotic certification in Brazil.

Educational note: teaching and training in robotic surgery. An opinion of the Minimally Invasive and Robotic Surgery Committee of the Brazilian College of Surgeons.

With the expansion of robotic surgical procedures, the acquisition of specific knowledge and skills for surgeons to reach proficiency seems essential before performing surgical procedures on humans. In this sense, the authors present a proposal to establish a certification based on objective and validated criteria for carrying out robotic procedures. A study was carried out by the Committee on Minimally Invasive and Robotic Surgery of the Brazilian College of Surgeons based on a reviewing strategy of the scientific literature. The study serves as a reference for the creation of a standard for the qualification and certification in robotic surgery according to a statement of the Brazilian Medical Association (AMB) announced on December 17, 2019. The standard proposes a minimum curriculum, integrating training and performance evaluation. The initial (pre-clinical) stage aims at knowledge and adaptation to a specific robotic platform and the development of psychomotor skills based on surgical simulation. Afterwards, the surgeon must accompany in person at least five surgeries in the specialty, participate as a bedside assistant in at least 10 cases and perform 10 surgeries under the supervision of a preceptor surgeon. The surgeon who completes all the steps will be considered qualified in robotic surgery in his specialty. The final certification must be issued by the specialty societies affiliated to AMB. The authors conclude that the creation of a norm for habilitation in robotic surgery should encourage Brazilian hospitals to apply objective qualification criteria for this type of procedure to qualify assistance.

Decision making process in simultaneous laparoscopic resection of colorectal cancer and liver metastases. Review of literature.

PURPOSE: The benefits of laparoscopic approaches to treat colorectal cancer (CRC) and colorectal liver metastases (CRLM) separately are well established. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged. The objective of this review with practical reports is to discuss technical aspects required for patient selection to perform simultaneous laparoscopic approaches for CRC and CRLM. METHODS: Literature review of oncological factors associated with patient selection for surgical treatment of CRLM and the use of laparoscopy in those cases, and report of technical aspects for simultaneous CRC and CRLM approaches. RESULTS: Simultaneous laparoscopic resection has been successful in many series of selected patients, although it seems to be safer to perform minor and major liver resection with non-extended colorectal resections, and to avoid two high-risk procedures at the same time. CONCLUSIONS: Simultaneous CRC and CRLM resections seem to be safe when patients are carefully selected, also considering the risk of recurrence concerning oncologic outcomes. The pre-planning of simultaneous resection is mandatory to plan trocar positioning, procedure sequencing, and patient position.

Study on the prevalence of human papillomavirus in the anal canal of women with cervical intraepithelial neoplasia grade III.

OBJECTIVE: The objective was to evaluate the prevalence of human papillomavirus (HPV) in the anal canal of women with cervical intraepithelial neoplasia (CIN) grade III. STUDY DESIGN: Two groups were compared. In group I (study group), 40 women who had undergone cervical biopsy with a histopathological result indicating CIN III were evaluated. Group II (control) consisted of 40 women with normal results from colposcopic examination and colpocytological tests. The women in group I who presented high-grade neoplasia in colpocytological tests underwent collection of material from the uterine cervix and anal canal for investigating HPV DNA using the Hybrid Capture II technique. Colposcopy and cervical biopsy were then performed. If CIN III was confirmed, HPV DNA was investigated in the material collected. In group II, colpocytological tests and colposcopy were performed and, if normal, the procedure was similar to that followed for group I, except that no biopsy was performed. RESULTS: In group I, 39 women (97.5%) were positive for HPV in the uterine cervix and 14 women (35%) in the anal canal. In group II, only four women (10%) had a positive HPV test, for both the uterine cervix and the anal canal. CONCLUSIONS: The prevalence of HPV in the anal canal of the women with CIN III was greater than in the women without CIN III.

Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Characterization of topoisomerase II α and minichromosome maintenance protein 2 expression in anal carcinoma.

The present study aimed to ascertain the significance of topoisomerase II α (TOP2A) and minichromosome maintenance protein (MCM) 2 expression in anal carcinoma. A total of 75 anal lesions were retrieved from the files of the Department of Pathology of Barretos Cancer Hospital (Barretos, Brazil) in order to verify the human papillomavirus (HPV) statuses of these lesions and characterize the immunohistochemical expression levels of TOP2A and MCM2 in anal carcinoma, as these are important markers for cervical HPV-induced lesions; their expression was also compared with respect to p16 and Ki-67. The vast majority of the cases tested positive for HPV16 (84%); 1 case tested positive for both HPV16 and HPV18. Positive HPV16 status was more frequent in early stages than in advanced stages (P=0.008). Positive immunohistochemical reactivity for MCM2 and TOP2A protein was observed in 71.6 and 100% of cases, respectively. Positive reactivity for p16 was significantly associated (P=0.001) with histological grade, and was more commonly expressed in squamous cell carcinoma than adenocarcinomas. HPV16 was strongly associated with positive p16 protein expression (76.6%). However, the high expression of Ki-67 combined with the high expression of p16 was predominantly observed in Stage III-IV cases. MCM2, TOP2A, p16 and Ki-67 exhibited intense positive staining in the anal lesions, indicating that these markers were significantly and constantly expressed in anal carcinoma.

Video-assisted thoracoscopic surgery in swine: an animal model for thoracoscopic lobectomy training.

OBJECTIVES: Minimally invasive thoracic procedures have been increasingly used; however, only a small number of lobectomies are performed by videothoracoscopy, showing the need for training on this technique. The objective of this study is to demonstrate the technique of lobectomy using videothoracoscopy in swine, highlighting the steps to be taken during its use in surgical experimentation. METHODS: During the advanced course on video-assisted and thoracoscopic procedures carried out at IRCAD Latin America, Barretos, Brazil, 40 swine were used for the hands-on course on video-assisted upper left lobectomy. Monopulmonary ventilation was performed by blocking the left main bronchus. Surgical procedures were performed using three ports and the anterior dissection technique (fissureless approach). The pulmonary hilar structures were dissected using conventional open surgery and video-assisted surgical tools. The first structure treated in the approach of the hilar structures was the upper lobe vein, followed by the bronchus and the branches of the pulmonary artery. RESULTS: The mean time required to anaesthetize the animals was 3 h. Intraoperative hypoventilation was observed in 26 animals (65%) and 4 (10%) of them had a poor outcome and died in the last third part of the surgery. Eight (20%) animals had bradycardia, and six responded to the use of atropine. In two (5%), it was not possible to revert the bradycardia and the animals died at the end of the procedures. The surgical procedures had a mean duration of 3 h and the total time of anaesthesia was about 6 h. DISCUSSION: Swine have been frequently used for hands-on training in surgery but there are no reports in the literature describing the anatomical, anaesthetic and technical peculiarities that must be observed during videothoracoscopic lobectomy training in swine. Video-assisted thoracoscopic surgery lobectomy using swine is an adequate method to train thoracic surgeons. For surgeons to make the best use of minimally invasive technique training, it is essential that issues related to the anatomy, anaesthesia, monopulmonary ventilation and surgical technique described in this study are taken into account.

Overview and perspectives about the robotic surgical certification process in Brazil: the new statement and a national web-survey / Visão geral e perspectivas sobre o processo de certificação em cirurgia robótica no Brasil: o novo regimento e uma pesquisa nacional online

ABSTRACT Objective: to appraise the general profile of the Brazilian robotic surgeon and the acknowledgment of the new certification process for robotic surgery upon the Associação Médica Brasileira (AMB - Brazilian Medical Association) statement. According to the AMB statement, medical societies and proctors have to achieve leading roles in training and certification of surgeons, acting in partnership with industry. Methods: a national web-based survey was promoted by the Colégio Brasileiro de Cirurgiões (CBC - Brazilian College of Surgeons) among their members. Results: the 294 answers were split into two groups: 133 (45.3%) who had robotic console certification, and 161 (54.8%) who did not have it. The overall median age was 46, but the non-robotic group presented more surgeons with at least 30 years of experience than to the robotic group (32.3% versus 23.3%, p=0.033). Surgeons with robotic certification more frequently work in a city with at least one million inhabitants than surgeons who were not certified (85.7 versus 63.4%, p<0.001). The majority of surgeons in both groups have similar positioning for all main points of the statement. However, the agreement proportions for the preceptors responsibility during the procedures were higher among non-robotic surgeons that expected the preceptor to assume co-responsibility for the procedure (85% versus 60.9%, p<0.001), and intervene during the procedure as much as necessary (97.5% versus 91.7%, p=0.033). Conclusion: the overall agreement of the answers to the AMB statement seems to be a promising pathway to increase the participation of the medical entities into the robotic certification in Brazil.

RESUMO Objetivo: avaliar o perfil do cirurgião robótico brasileiro e seu reconhecimento sobre o novo processo de certificação para cirurgia robótica que consta na declaração da Associação Médica Brasileira (AMB). De acordo com a declaração da AMB, as sociedades médicas e os preceptores devem alcançar papéis de liderança no treinamento e certificação de cirurgiões, atuando em parceria com a indústria. Métodos: uma pesquisa nacional pela Internet foi promovida pelo Colégio Brasileiro de Cirurgiões com seus membros. Resultados: entre as 294 respostas, os cirurgiões foram divididas em dois grupos: 133 (45,3%) que possuíam certificação de console robótico e 161 (54,8%) que não possuíam. A média geral de idade foi de 46 anos, mas o grupo não robótico teve mais cirurgiões com pelo menos 30 anos de experiência (32,3% versus 23,3%, p = 0,033). Cirurgiões com certificação robótica trabalhavam mais frequentemente em cidades mais populosas, com pelo menos um milhão de habitantes (85,7 versus 63,4%, p <0,001). A maioria dos cirurgiões de ambos os grupos tem posicionamento semelhante para todos os pontos principais da declaração. No entanto, as proporções de concordância para a responsabilidade do preceptor durante os procedimentos foram maiores entre os cirurgiões não robóticos que esperavam que o preceptor assumisse corresponsabilidade pelo procedimento (85% versus 60,9%, p <0,001), e que intervenha , tanto quanto necessário (97,5% versus 91,7%, p = 0,033). Conclusão: a aceitação por parte da maioria dos profissionais em relação à declaraçãoda AMB parece ser caminho promissor para aumentar a participação das entidades médicas na certificação robótica no Brasil.

Educational note: teaching and training in robotic surgery. An opinion of the Minimally Invasive and Robotic Surgery Committee of the Brazilian College of Surgeons / Nota educacional: ensino e treinamento em cirurgia robótica. Um parecer da Comissão de Cirurgia Minimamente Invasiva e Robótica

ABSTRACT With the expansion of robotic surgical procedures, the acquisition of specific knowledge and skills for surgeons to reach proficiency seems essential before performing surgical procedures on humans. In this sense, the authors present a proposal to establish a certification based on objective and validated criteria for carrying out robotic procedures. A study was carried out by the Committee on Minimally Invasive and Robotic Surgery of the Brazilian College of Surgeons based on a reviewing strategy of the scientific literature. The study serves as a reference for the creation of a standard for the qualification and certification in robotic surgery according to a statement of the Brazilian Medical Association (AMB) announced on December 17, 2019. The standard proposes a minimum curriculum, integrating training and performance evaluation. The initial (pre-clinical) stage aims at knowledge and adaptation to a specific robotic platform and the development of psychomotor skills based on surgical simulation. Afterwards, the surgeon must accompany in person at least five surgeries in the specialty, participate as a bedside assistant in at least 10 cases and perform 10 surgeries under the supervision of a preceptor surgeon. The surgeon who completes all the steps will be considered qualified in robotic surgery in his specialty. The final certification must be issued by the specialty societies affiliated to AMB. The authors conclude that the creation of a norm for habilitation in robotic surgery should encourage Brazilian hospitals to apply objective qualification criteria for this type of procedure to qualify assistance.

RESUMO Com a expansão da realização de procedimentos cirúrgicos robóticos, a aquisição de conhecimentos e habilidades específicas para que o cirurgião alcance proficiência antes de realizar procedimentos cirúrgicos em humanos torna-se fundamental. Neste sentido, os autores apresentam uma proposta de estabelecimento de uma certificação baseada em critérios objetivos e validados para a realização de procedimentos robóticos. Um estudo foi executado pela Comissão de Cirurgia Minimamente Invasiva e Robótica do Colégio Brasileiro de Cirurgiões baseado em uma estratégia de revisão da literatura científica. O estudo serve de referência para a criação de uma normativa para a habilitação e certificação em cirurgia robótica de acordo com comunicado da Associação Médica Brasileira anunciado em 17 de dezembro de 2019. A normativa propõe um currículo mínimo, integrando treinamento e avaliação de desempenho. A etapa inicial (pré-clínica) visa o conhecimento e adaptação a uma plataforma robótica específica e o desenvolvimento de habilidades psicomotoras baseada em simulação cirúrgica. Após, o cirurgião deverá acompanhar presencialmente pelo menos cinco cirurgias na especialidade, participar como cirurgião auxiliar em pelo menos 10 casos e realizar 10 cirurgias sob supervisão de um cirurgião preceptor. O cirurgião que concluir todas as etapas será considerado habilitado em cirurgia robótica em sua especialidade. A certificação de habilitação definitiva deverá ser emitida pelas sociedades de especialidades filiadas à AMB. Os autores concluem que a criação de uma normativa para habilitação em cirurgia robótica deve estimular que os hospitais brasileiros apliquem critérios objetivos de habilitação para este tipo de procedimento, no sentido de qualificar a assistência.

Decision making process in simultaneous laparoscopic resection of colorectal cancer and liver metastases. Review of literature

Abstract Purpose: The benefits of laparoscopic approaches to treat colorectal cancer (CRC) and colorectal liver metastases (CRLM) separately are well established. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged. The objective of this review with practical reports is to discuss technical aspects required for patient selection to perform simultaneous laparoscopic approaches for CRC and CRLM. Methods: Literature review of oncological factors associated with patient selection for surgical treatment of CRLM and the use of laparoscopy in those cases, and report of technical aspects for simultaneous CRC and CRLM approaches. Results: Simultaneous laparoscopic resection has been successful in many series of selected patients, although it seems to be safer to perform minor and major liver resection with non-extended colorectal resections, and to avoid two high-risk procedures at the same time. Conclusions: Simultaneous CRC and CRLM resections seem to be safe when patients are carefully selected, also considering the risk of recurrence concerning oncologic outcomes. The pre-planning of simultaneous resection is mandatory to plan trocar positioning, procedure sequencing, and patient position.