The Learning Curve for Robotic Lateral Pelvic Lymph Node Dissection for Rectal Cancer: A View From the West.

BACKGROUND: Lateral pelvic lymph node dissection is performed for selected patients with rectal cancer with persistent lateral nodal disease after neoadjuvant therapy. This technique has been slow to be adopted in the West because of concerns regarding technical difficulty. This is the first report on the learning curve for lateral pelvic lymph node dissection in the United States or Europe. OBJECTIVE: This study aimed to analyze the learning curve associated with robotic lateral pelvic lymph node dissection. DESIGN: Retrospective observational cohort. SETTING: Tertiary academic cancer center. PATIENTS: Consecutive patients from 2012 to 2021. INTERVENTION: All patients underwent robotic lateral pelvic lymph node dissection. MAIN OUTCOME MEASURES: The primary end points were the learning curves for the maximum number of nodes retrieved and urinary retention, which was evaluated with simple cumulative sum and 2-sided Bernoulli cumulative sum charts. RESULTS: Fifty-four procedures were included. A single-surgeon learning curve (n = 35) and an institutional learning curve are presented in the analysis. In the single-surgeon learning curve, a turning point marking the end of a learning phase was detected at the 12th procedure for the number of retrieved nodes and at the 20th procedure for urinary retention. In the institutional learning curve analysis, 2 turning points were identified at the 13th procedure, indicating progressive improvements for the number of retrieved nodes, and at the 27th procedure for urinary retention. No sustained alarm signals were detected at any time point. LIMITATIONS: The retrospective nature, small sample size, and the referral center nature of the reporting institution may limit generalizability. CONCLUSIONS: In a setting of institutional experience with robotic colorectal surgery, including beyond total mesorectal excision resections, the learning curve for robotic lateral pelvic lymph node dissection is acceptably short. Our results demonstrate the feasibility of the acquisition of this technique in a controlled setting, with sufficient case volume and proctoring to optimize the learning curve. See Video Abstract. LA CURVA DE APRENDIZAJE DE LA DISECCIN ROBTICA DE LOS GANGLIOS LINFTICOS PLVICOS LATERALES EN EL CNCER DE RECTO UNA VISIN DESDE OCCIDENTE: ANTECEDENTES:La disección lateral de los ganglios linfáticos pélvicos se realiza en pacientes seleccionados con cáncer de recto con enfermedad ganglionar lateral persistente tras el tratamiento neoadyuvante. La adopción de esta técnica en Occidente ha sido lenta debido a la preocupación por su dificultad técnica. Éste es el primer informe sobre la curva de aprendizaje de la disección de los ganglios linfáticos pélvicos laterales en EE.UU. o Europa.OBJETIVO:El objetivo de este estudio fue analizar la curva de aprendizaje asociada a la disección robótica de los ganglios linfáticos pélvicos laterales.DISEÑO:Cohorte observacional retrospectiva.LUGAR:Centro oncológico académico terciario.PACIENTES:Pacientes consecutivos desde 2012 al 2021.INTERVENCIÓN:Todos los pacientes fueron sometieron a disección robótica de ganglios linfáticos pélvicos laterales.PRINCIPALES MEDIDAS DE RESULTADO:Los criterios de valoración primarios fueron las curvas de aprendizaje tomando en cuenta el mayor número de ganglios recuperados y la retención urinaria que fueron evaluados con gráficos de suma acumulativa simple y de suma acumulativa de Bernoulli de dos caras.RESULTADOS:Fueron incluidos 54 procedimientos. En el análisis se presentan una curva de aprendizaje de un solo cirujano (n = 35) y una curva de aprendizaje institucional. En la curva de aprendizaje de un solo cirujano, se detectó un punto de inflexión que marcaba el final de una fase de aprendizaje en el duodécimo procedimiento para el número de ganglios extraídos y en el vigésimo para la retención urinaria. En el análisis de la curva de aprendizaje institucional, se identificaron dos puntos de inflexión en las intervenciones 13.ª y 26.ª, que indicaron mejoras progresivas en el número de ganglios extraídos, y en la 27.ª en la retención urinaria. No se detectaron señales de alarma sostenidas en ningún momento.LIMITACIONES:La naturaleza retrospectiva, el pequeño tamaño de la muestra y la naturaleza de centro de referencia de la institución informante que pueden limitar la capacidad de generalizarse.CONCLUSIONES:En un entorno de experiencia institucional con cirugía robótica colorrectal incluyendo más allá de las resecciones TME, la curva de aprendizaje para la disección robótica de ganglios linfáticos pélvicos laterales es aceptablemente corta. Nuestros resultados demuestran la viabilidad de la adquisición de esta técnica en un entorno controlado, con un volumen de casos suficiente y una supervisión que puede optimizar la curva de aprendizaje. (Traducción-Dr. Osvaldo Gauto ).

Utility of a Three-Dimensional Printed Pelvic Model for Lateral Pelvic Lymph Node Dissection Education: A Randomized Controlled Trial.

BACKGROUND: Lateral pelvic lymph node dissection for rectal cancer is a difficult technique due to the complex pelvic anatomy involved. Three-dimensional (3D) organ models have been introduced as education tools to study anatomy in some fields. In this study, we educated the participants about pelvic anatomy using a 3D model, and evaluated learning efficiency, comparing the outcomes with those using a traditional textbook. STUDY DESIGN: This study was a randomized, controlled, single-center trial conducted between July 2018 and July 2019. A total of 102 participants (34 medical students, 34 residents, and 34 surgeons) were enrolled. Participants were randomly assigned to the 3D model group or the textbook group. First, they completed a short test to confirm their basic knowledge before further education. After collocated education, they completed the same short test again and another long test to evaluate their learning outcomes. RESULTS: Before education, there was no significant difference in the short test scores between the 3D model group and the textbook group. After education, the short and long test scores of the 3D model group were significantly higher than those of the textbook group for students (short test; p = 0.05, long test; p = 0.03), residents (short test; p = 0.05, long test; p = 0.002), and surgeons (short test; p = 0.009, long test; p < 0.001). CONCLUSIONS: Using a 3D pelvic model is superior to using a textbook when learning pelvic anatomy required for lateral pelvic lymph node dissection.

Decreasing rates of axillary lymph node dissections over time: Implications for surgical resident exposure and operative skills development.

BACKGROUND: Sentinel lymph node biopsy has supplanted axillary lymph node dissection (ALND) in clinically node-negative breast cancer and select node-positive disease. We hypothesized a decreasing rate of both ALND and resident exposure over time. METHODS: We identified women with clinical Stage I-III breast cancer in the National Cancer Data Base (2004-2014). Adjusted multivariate logistic regression was used to estimate the effect of various factors on receipt of ALND. Yearly procedural rates for residents were extracted from surgical case log reports for comparison against procedural rates. RESULTS: 1,131,363 patients were identified; 255,306 received ALND, 876,057 underwent non-ALND management. ALND rates declined from 2004 (32%) to 2014 (16%, p < 0.001), with the largest decline occurring between 2010 and 2011 (24%-20%). After adjustment, this effect was maintained, with ALND rates decreasing with each additional year (OR = 0.90, 95% CI 0.89-0.90). Resident procedure volumes similarly declined from 1999 to 2017 (p < 0.001). CONCLUSIONS: Significant declines in both ALND rates and procedural volume in residency may impact outcomes, as ALNDs are being performed in ever more challenging oncologic scenarios by potentially less-experienced surgeons.

Learning Curve of Robotic Rectal Surgery With Lateral Lymph Node Dissection: Cumulative Sum and Multiple Regression Analyses.

OBJECTIVE: This study aimed to assess the learning curve of robotic rectal surgery, a procedure that has gained increasing focus in recent years because it is expected that the advanced devices used in this approach provide advantages resulting in a shorter learning curve than that of laparoscopic surgery. However, no studies have assessed the learning curve of robotic rectal surgery, especially when lateral lymph node dissection is required. DESIGN: This was a nonrandomized, retrospective study from a single institution. SETTING: All consecutive patients who underwent robotic rectal or sigmoid colon surgery by a single surgeon between February 2012 and July 2016 in the University of Tokyo Hospital were enrolled. The learning curve for console time was assessed using a cumulative sum analysis and multiple linear regression analysis. PARTICIPANTS: A total of 131 consecutive patients underwent robotic rectal or sigmoid colon surgery performed by a single experienced surgeon. Of these, 41 patients received lateral lymph node dissection. RESULTS: A cumulative sum plot for console time demonstrated that the learning period could be divided into 3 phases: Phase I, Cases 1 to 19; Phase II, Cases 20 to 78; and Phase III, Cases 79 to 131. Multiple linear regression analysis indicated that console time decreased significantly from one phase to another (Phase I-II, Δconsole time 83.0 minutes; Phase II-III, Δconsole time 40.1 minutes). Other factors affecting console time included body mass index, operative procedure, and lateral lymph node dissection, but not neoadjuvant therapy (such as chemoradiotherapy) or depth of invasion. Lateral lymph node dissection required an additional 138.4 minutes. CONCLUSIONS: Our findings suggest that the first phase of the learning curve consists of the first 19 cases, which seems sufficient to master the manipulation of robotic arms and to understand spatial relationships unique to the robotic procedure.

Utility of preoperative 3-D simulation of laparoscopic lateral pelvic lymph node dissection for advanced rectal cancer: Surgical outcomes of 10 initial cases.

INTRODUCTION: Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer. METHODS: After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images. RESULTS: A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications. CONCLUSION: Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.

A study of the learning curve for robotic oesophagectomy for oesophageal cancer.

OBJECTIVES: Robot-assisted minimally invasive oesophagectomy (RAMIE) enables radical, meticulous dissection of the oesophagus and lymph nodes. Our goal was to identify the effect of the learning curve for RAMIE when performing radical upper mediastinal dissection in patients with oesophageal cancer. METHODS: We conducted a retrospective review of a prospectively maintained database of patients who underwent RAMIE for oesophageal cancer between May 2008 and July 2016. The gain in proficiency for each postoperative outcome measure was presented using observed-expected cumulative sum (O-E CUSUM) curves. The change points were defined at the maximal distance from the zero axis. RESULTS: A total of 140 patients were included. Squamous cell carcinoma (n = 131, 93.6%) was the dominant type. Thirty-day and 90-day deaths occurred in 1 and 5 patients (0.7% and 3.6%, respectively). The change points of the risk-adjusted O-E CUSUM curves were similar to those of the unadjusted O-E CUSUM curves with the exception of those for thoracic procedure time and vocal cord palsy. The number of harvested lymph nodes increased from 25 to 45 before and after 30 cases. The vocal cord palsy rate decreased from 36% to 17% before and after 60 cases. The total operation time decreased from 496 min to 431 min; the length of the hospital stay decreased from 24 days to 14 days; and the anastomotic leakage rate decreased from 15% to 2% before and after 80 cases. CONCLUSIONS: Our study demonstrated a temporal improvement in postoperative outcomes based on accumulated experience with RAMIE. The risk-adjusted O-E CUSUM curves were similar to the unadjusted O-E CUSUM curves, which represents the significant impact of the effect of a learning period on the postoperative outcomes of RAMIE in patients with oesophageal cancer.

Live surgery: highly educational or harmful?

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

[Initial Experience with Uniportal Video-Assisted Thoracoscopic Surgery for Anatomical Lung Resections: A Propensity Score Study and an Observational Assessment of the Learning Curve]. / Uniportale videoassistiert-thorakoskopische anatomische Lungenresektionen: erste Erfahrungen und ein Vergleich mit dem multiportalen Zugang.

INTRODUCTION: Uniportal video-assisted thoracoscopic surgery (UVATS) for anatomical lung resections has gained popularity of late. This study aimed to elucidate the impediments to implementing the uniportal access method into the daily routine of VATS lung resections. To this end, we reviewed our initial experience and evaluated our progress. METHODS: From January to May 2016, 24 consecutive UVATS anatomical lung resections (UVATS group) were performed by a single surgeon without any previous experience in UVATS surgery. These cases were matched in a one-to-one fashion with a cohort of 102 patients who had undergone "classical" VATS anatomical lung resections (VATS group) in the past 2’years performed by the same surgeon, using the nearest estimated propensity score. Based on an initial analysis, the UVATS group was further divided into two subgroups, UVATS1 and UVATS2, consisting of the first and last 12 cases. RESULTS: No UVATS patient required conversion to thoracotomy or needed an additional port. The VATS group had a shorter mean operation time if compared with the UVATS1 subgroup (MVATS = 152, MUVATS1 = 191; p = 0.019), but not if compared with the UVATS2 subgroup (MVATS = 152, MUVATS2 = 152; p = 1). There was no difference between the groups in the number of lymph node stations sampled (MVATS = 7, MUVATS1 = 7, MUVATS2 = 7; p = 0.92), the average number of dissected lymph nodes (MVATS = 19, MUVATS1 = 15, MUVATS2 = 18; p = 0.659), and the number and type of postoperative complications. As demonstrated on an audio-analogue pain scale (AAS), the UVATS groups needed significantly less pain medication until discharge (p < 0.001). CONCLUSION: The adoption of uniportal VATS for anatomical lung resections can be accomplished without any impact on operative or clinical success, if performed by a surgeon already experienced in "classical" VATS. In our experience, there was no need for additional courses, proctored cases or modification of surgical instruments, although all options mentioned above may facilitate adoption.

Attending Surgeon Variation in Operative Case Length: An Opportunity for Quality Improvement.

Balancing resident education with operating room (OR) efficiency, while accommodating different styles of surgical educators and learners, is a challenging task. We sought to evaluate variability in operative time for breast surgery cases. Accreditation Council for Graduate Medical Education case logs of breast operations from 2011 to 2017 for current surgical residents at Loma Linda University were correlated with patient records. The main outcome measure was operative time. Breast cases were assessed as these operations are performed during all postgraduate years (PGY). Breast procedures were grouped according to similarity. Variables analyzed included attending surgeon, PGY level, procedure type, month of operation, and American Society of Anesthesiologists class. Of 606 breast cases reviewed, median overall operative time was 150 minutes (interquartile range 187-927). One-way analysis of covariance demonstrated statistically significant variation in operative time by attending surgeon controlling for covariates (PGY level, procedure, American Society of Anesthesiologists class, and month) (P = 0.04). With institutional OR costs of $30 per minute, the average difference between slowest and fastest surgeon was $2400 per case [(218-138) minutes × $30/min]. Minimizing variability for common procedures performed by surgical educators may enhance OR efficiency. However, the impact of case length on surgical resident training requires careful consideration.

The effect of a multidisciplinary regional educational programme on the quality of colon cancer resection.

AIM: Mesocolic plane surgery with central vascular ligation produces an oncologically superior specimen following colon cancer resection and appears to be related to optimal outcomes. We aimed to assess whether a regional educational programme in optimal mesocolic surgery led to an improvement in the quality of specimens. METHOD: Following an educational programme in the Capital and Zealand areas of Denmark, 686 cases of primary colon cancer resected across six hospitals were assessed by grading the plane of surgery and undertaking tissue morphometry. These were compared to 263 specimens resected prior to the educational programme. RESULTS: Across the region, the mesocolic plane rate improved from 58% to 77% (P < 0.001). One hospital had previously implemented optimal surgery as standard prior to the educational programme and continued to produce a high rate of mesocolic plane specimens (68%) with a greater distance between the tumour and the high tie (median for all fresh cases: 113 vs 82 mm) and lymph node yield (33 vs 18) compared to the other hospitals. Three of the other hospitals showed a significant improvement in the plane of surgical resection. CONCLUSION: A multidisciplinary regional educational programme in optimal mesocolic surgery improved the oncological quality of colon cancer specimens as assessed by mesocolic planes; however, there was no significant effect on the amount of tissue resected centrally. Surgeons who attempt central vascular ligation continue to produce more radical specimens suggesting that such educational programmes alone are not sufficient to increase the amount of tissue resected around the tumour.

Development and Validation of Objective Performance Metrics for Robot-Assisted Radical Prostatectomy: A Pilot Study.

PURPOSE: We explore and validate objective surgeon performance metrics using a novel recorder ("dVLogger") to directly capture surgeon manipulations on the da Vinci® Surgical System. We present the initial construct and concurrent validation study of objective metrics during preselected steps of robot-assisted radical prostatectomy. MATERIALS AND METHODS: Kinematic and events data were recorded for expert (100 or more cases) and novice (less than 100 cases) surgeons performing bladder mobilization, seminal vesicle dissection, anterior vesicourethral anastomosis and right pelvic lymphadenectomy. Expert/novice metrics were compared using mixed effect statistical modeling (construct validation). Expert reviewers blindly rated seminal vesicle dissection and anterior vesicourethral anastomosis using GEARS (Global Evaluative Assessment of Robotic Skills). Intraclass correlation measured inter-rater variability. Objective metrics were correlated to corresponding GEARS metrics using Spearman's test (concurrent validation). RESULTS: The performance of 10 experts (mean 810 cases, range 100 to 2,000) and 10 novices (mean 35 cases, range 5 to 80) was evaluated in 100 robot-assisted radical prostatectomy cases. For construct validation the experts completed operative steps faster (p <0.001) with less instrument travel distance (p <0.01), less aggregate instrument idle time (p <0.001), shorter camera path length (p <0.001) and more frequent camera movements (p <0.03). Experts had a greater ratio of dominant-to-nondominant instrument path distance for all steps (p <0.04) except anterior vesicourethral anastomosis. For concurrent validation the median experience of 3 expert reviewers was 300 cases (range 200 to 500). Intraclass correlation among reviewers was 0.6-0.7. For anterior vesicourethral anastomosis and seminal vesicle dissection, kinematic metrics had low associations with GEARS metrics. CONCLUSIONS: Objective metrics revealed experts to be more efficient and directed during preselected steps of robot-assisted radical prostatectomy. Objective metrics had limited associations to GEARS. These findings lay the foundation for developing standardized metrics for surgeon training and assessment.

Learning curve in concurrent application of laparoscopic and robotic-assisted hysterectomy with lymphadenectomy in endometrial cancer.

OBJECTIVE: To evaluate the concurrent interaction of laparoscopic and robotic-assisted surgery in the initial learning period of endometrial cancer staging. MATERIALS AND METHODS: A retrospective cohort study was performed for the first 44 consecutive patients with endometrial cancer underwent laparoscopic (LSS) or robotic-assisted staging surgery (RSS) from February 2012 to October 2015 by a single surgeon in a tertiary care referral hospital. Demographics, diagnosis, perioperative variables, and complications were recorded. Quality of surgery was determined by the number of lymph nodes dissected and learning curve was estimated by operative time with respect to chronologic order of operation. RESULTS: Twenty-four patients received LSS and 20 patients received RSS. RSS required longer operative time, but obtained more total number of lymph nodes compared with LSS (286.9 vs. 201.9 min (p < 0.001); 26.2 vs. 20.7 (p < 0.05), respectively. There were no difference in blood loss, number of para-aortic nodes removed, complications and hospital stay between the two types of surgery. An additive model based on tumor grade, body mass index, estimated blood loss and chronological order of operation was constructed to fit operative time of these two types of surgery. Proficiency of achievement was not observed for LSS and was 6 for RSS. CONCLUSIONS: Operative time was longer but Lymph node dissection was easier in RSS. Learning curve for LSS to maintain similar surgical quality as RSS was not observed. The concurrent use of robotic platform in the initial practice of minimally invasive staging surgery could optimize surgical technique for LSS.

Advanced real-time multi-display educational system (ARMES): An innovative real-time audiovisual mentoring tool for complex robotic surgery.

INTRODUCTION: The recent scientific and technologic advances have profoundly affected the training of surgeons worldwide. We describe a novel intraoperative real-time training module, the Advanced Robotic Multi-display Educational System (ARMES). METHODS: We created a real-time training module, which can provide a standardized step by step guidance to robotic distal subtotal gastrectomy with D2 lymphadenectomy procedures, ARMES. The short video clips of 20 key steps in the standardized procedure for robotic gastrectomy were created and integrated with TilePro™ software to delivery on da Vinci Surgical Systems (Intuitive Surgical, Sunnyvale, CA). RESULTS: We successfully performed the robotic distal subtotal gastrectomy with D2 lymphadenectomy for patient with gastric cancer employing this new teaching method without any transfer errors or system failures. Using this technique, the total operative time was 197 min and blood loss was 50 mL and there were no intra- or post-operative complications. CONCLUSIONS: Our innovative real-time mentoring module, ARMES, enables standardized, systematic guidance during surgical procedures.

Robotic technology for colorectal surgery : Procedures, current applications, and future innovative challenges.

BACKGROUND: Colorectal cancer is the third most common cancer worldwide. Current treatment approaches are multidisciplinary, including neoadjuvant chemoradiotherapy for rectal cancer. Several studies have reported an improvement in surgical techniques and in new devices facilitating better pre- and intraoperative staging. OBJECTIVES: Since its first application in 2002, robotic surgery has progressed steadily, offering good surgical results and better oncological outcomes. Currently, many studies and reviews have confirmed its safety and feasibility for colorectal cancer. MATERIALS AND METHODS: Robotic technology simplifies surgical maneuvers thanks to the three-dimensional magnification and stable vision, convenient mobility of the robotic arms, endowrist instruments with seven degrees of freedom, ambidextrous capability, tremor filtering, and indocyanine green fluorescence imaging. RESULTS: Regarding the oncological outcome, the robotic technique is equivalent to the laparoscopic approach; however, a lower recurrence rate has been achieved with the robotic approach in extended lymphadenectomy as part of complete mesocolic excision for right colonic cancer and total mesorectal excision for low rectal tumors. CONCLUSION: Colorectal robotic surgery has progressively improved worldwide. Its advantages are related not only to better oncological outcomes, but also to improvements in terms of detection, accurate diagnosis, and staging.

Robot-assisted minimally invasive esophagectomy.

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.