A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system.

PURPOSE: Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness. METHODS: This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery. RESULTS: 45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case). CONCLUSION: With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.

Effect of epidural analgesia on postoperative opioid requirements following elective laparotomies performed at Vancouver General Hospital.

BACKGROUND: Enhanced recovery pathways aim to reduce postoperative opioid use and opioid-related complications. These pathways often include epidural analgesia (EA). This study examines postoperative opioid use after elective laparotomy with and without EA. METHODS: Retrospective chart review of elective laparotomies performed by General Surgery at a tertiary academic center during 2017 was completed. Primary outcome was postoperative opioid usage. Secondary outcomes were time to mobilization, duration of urinary catheterization and postoperative ileus. RESULTS: Among 236 patients, 213 (90%) received EA. There was no significant difference in mean total oral morphine equivalent (OME) usage between EA and non-EA groups. Mean OME use on postoperative day three was higher in the EA group (38.0 vs 22.4 mg, p = 0.02). On multivariate analysis, preoperative opioid use was associated with increased postoperative OME consumption (regression coefficient 147.5, p < 0.001). CONCLUSIONS: In this cohort, epidural analgesia did not reduce postoperative opioid consumption.

Reducing time from colon cancer surgery to initiation of adjuvant chemotherapy: pilot project.

Summary: Surgical resection followed by adjuvant chemotherapy is the standard of care for patients with stage III colon cancer. To shorten the time interval between surgery and chemotherapy in patients with colon cancer, we instituted a standardized referral pathway. Evaluation of the intervention demonstrated that referring our patients with colon cancer to a medical oncologist earlier in the treatment process increased the number of patients in whom chemotherapy was initiated within 8 weeks compared with historical controls. These results support early medical oncology referral at institutions where delays in adjuvant chemotherapy initiation exist.

Fluorescent Cholangiography in Laparoscopic Cholecystectomy: An Updated Canadian Experience.

Background. Laparoscopic cholecystectomy (LC) is one of the most common general surgery procedures in Canada with approximately 100 000 cases performed per year. Bile duct injury remains a morbid complication with an incidence rate of 0.3% to 0.5%. Indocyanine green (ICG) fluorescent cholangiography is a noninvasive technology aiding in real-time identification of biliary structures for safe dissection within Calot's triangle. The objectives were to provide an update to our initial experience with ICG aiding in the identification of biliary structures and ensuring that no adverse patient reactions occurred with ICG administration. Methods. Prospective case series from 2016 to 2018 for elective LC with ICG technology performed at a single academic teaching institution. Patient demographics, indications for operation, biliary structures visualized, amount of ICG used, operative times, and complications were recorded. Results. One hundred eight cases were included for review. The cystic duct, common hepatic duct, and common bile duct were identified with ICG in 90%, 48%, and 84% of cases, respectively. ICG simultaneously visualized at least 2 of 3 biliary structures 83.4% of the time. Only 1 biliary structure was identified in 10% of cases. No biliary structures were identified in 6% of cases. Mean initial ICG dose given was 1.65 mL. No adverse patient reactions to ICG were noted. Conclusions. This updated series illustrates that administration of ICG enhances visualization of the biliary system during outpatient LC. ICG is safe and its application should be further studied in early LC for acute cholecystitis.

Incisional wound VAC and risk-adjusted SSI rates in colorectal surgery: A tertiary centre experience.

BACKGROUND: In colorectal surgery, indications for incisional negative pressure wound therapy (iVAC) remain unclear. We sought to compare rates of surgical site infection (SSI) in patients who received iVAC or standard sterile dressing (SSD). METHODS: Institutional colorectal NSQIP data between 2014 and 2018 was reviewed. SSI rates were compared between iVAC and SSD cohorts using the NSQIP surgical risk calculator (NSQIP SRC) for risk-adjusted analysis. Secondary outcomes included other wound complications, morbidity, mortality, disposition destination and overall length of stay. RESULTS: 145 patients received iVAC while 544 received SSD. SSI was greater in iVAC than SSD (17% vs 9%, p = 0.009). iVAC was independently associated with SSI (OR 2.3, 95% CI 1.3-3.9). The presence of a colostomy strengthened this relationship. There was no difference in secondary outcomes. CONCLUSION: iVAC was independently associated with SSI with risk-adjusted analysis. This relationship was stronger in patients with a colostomy.

Fluorescent cholangiography in laparoscopic cholecystectomy: the initial Canadian experience.

BACKGROUND: Bile duct injury remains a worrisome complication of laparoscopic cholecystectomy. Indocyanine Green (ICG) fluorescent cholangiography (FC) is a new approach that facilitates real-time intraoperative identification of biliary anatomy. This technology is hoped to improve the safety of dissection within Calot's triangle. METHOD: Demographics, intraoperative details, and subjective surgeon data were recorded for elective cholecystectomy cases involving ICG. Goals were to identify rates of bile duct identification, and assess the perceived benefit of the device. RESULTS: ICG was used in 12 biliary cases in Canada. Visualization rates of the cystic and common bile ducts were 100% and 83%, respectively. Also, 83% of surgeons felt that FC incorporated smoothly into the operation. No complications have been related to the technology. CONCLUSIONS: FC allows noninvasive real-time visualization of the extrahepatic biliary tree. This novel technique has received positive feedback in its initial Canadian use and will likely be a durable adjunct for minimally invasive surgery.

Rigid vs articulating instrumentation for task completion in single-port surgery.

BACKGROUND: Single-port access surgery (SPA) may provide benefits but there is a steep learning curve. We compare traditional in-line instruments with articulating instruments. METHODS: Fundamentals of laparoscopic surgery peg transfer task was performed using a 3-port approach or SPA device. Standard rigid instrumentation was compared with articulating instrumentation. RESULTS: Twenty surgeons completed all tasks. Average time using a conventional approach was shorter than SPA (144 ± 54 vs 198 ± 74 seconds, P < .001). Articulating instruments required longer procedural time than rigid instrumentation (201 ± 66 vs 141 ± 58 seconds, P < .001). In the conventional model, task time was lower with rigid instruments than with articulating instruments (108 vs 179 seconds, P < .001). Task time in the SPA model was lower with rigid instruments (173 vs 223 seconds, P =.013). CONCLUSIONS: All tasks required longer time to complete in SPA when compared with a conventional approach. Articulating instruments have an increased benefit in SPA surgery.

Using three-dimensional laparoscopy as a novel training tool for novice trainees compared with two-dimensional laparoscopy.

BACKGROUND: Laparoscopic skills training is an essential component of general surgery training. This study proposes the use of three-dimensional (3D) laparoscopy as the initial training tool for beginners to shorten the learning curve. METHODS: This study evaluates the surgical performance and subjective experience of junior and senior trainees with 3D versus two-dimensional laparoscopy. Peg transfer task was used as the objective time measurement. A subjective evaluation of the 2 systems using a questionnaire was also used. RESULTS: The mean difference in the juniors was 16.33 seconds, while in the seniors it was only 3.46 seconds (P = .036). The time difference between groups was much smaller in the 3D than the two-dimensional (P = .14 vs .02) laparoscopy. In the subjective evaluation, the novice group also scored significantly higher for the 3D system in the bimanual dexterity category (P = .004, .007). CONCLUSION: Our study demonstrates the feasibility of using 3D laparoscopy for laparoscopic skills training in novices.

What do surgeons see: capturing and synchronizing eye gaze for surgery applications.

Recording eye motions in surgical environments is challenging. This study describes the authors' experiences with performing eye-tracking for improving surgery training, both in the laboratory and in the operating room (OR). Three different eye-trackers were used, each with different capabilities and requirements. For monitoring eye gaze shifts over the room scene in a simulated OR, a head-mounted system was used. The number of surgeons' eye glances on the monitor displaying patient vital signs was successfully captured by this system. The resolution of the head-mounted eye-tracker was not sufficient to obtain the gaze coordinates in detail on the surgical display monitor. The authors then selected a high-resolution eye-tracker built in to a 17-inch computer monitor that is capable of recording gaze differences with resolution of 1° of visual angle. This system enables one to investigate surgeons' eye-hand coordination on the surgical monitor in the laboratory environment. However, the limited effective tracking distance restricts the use of this system in the dynamic environment in the real OR. Another eye-tracker system was found with equally high level of resolution but with more flexibility on the tracking distance, as the eye-tracker camera was detached from the monitor. With this system, the surgeon's gaze during 11 laparoscopic procedures in the OR was recorded successfully. There were many logistical challenges with unobtrusively integrating the eye-tracking equipment into the regular OR workflow and data processing issues in the form of image compatibility and data validation. The experiences and solutions to these challenges are discussed.

Analysis of eye gaze: do novice surgeons look at the same location as expert surgeons during a laparoscopic operation?

INTRODUCTION: Eye-gaze technology can be used to track the gaze of surgeons on the surgical monitor. We examine the gaze of surgeons performing a task in the operating room and later watching the operative video in a lab. We also examined gaze of video watching by surgical residents. METHODS: Data collection required two phases. Phase 1 involved recording the real-time eye gaze of expert surgeons while they were performing laparoscopic procedures in the operating room. The videos were used for phase 2. Phase 2 involved showing the recorded videos to the same expert surgeons, and while they were watching the videos (self-watching), their eye gaze was recorded. Junior residents (PGY 1-3) also were asked to watch the videos (other-watching) and their eye gaze was recorded. Dual eye-gaze similarity in self-watching was computed by the level of gaze overlay and compared with other-watching. RESULTS: Sixteen cases of laparoscopic cholecystectomy were recorded in the operating room. When experts watched the videos, there was a 55% overlap of eye gaze; yet when novices watched, only a 43.8% overlap (p < 0.001) was shown. CONCLUSIONS: These findings show that there is a significant difference in gaze patterns between novice and expert surgeons while watching surgical videos. Expert gaze recording from the operating room can be used to make teaching videos for gaze training to expedite learning curves of novice surgeons.

Workload assessment of surgeons: correlation between NASA TLX and blinks.

BACKGROUND: Blinks are known as an indicator of visual attention and mental stress. In this study, surgeons' mental workload was evaluated utilizing a paper assessment instrument (National Aeronautics and Space Administration Task Load Index, NASA TLX) and by examining their eye blinks. Correlation between these two assessments was reported. METHODS: Surgeons' eye motions were video-recorded using a head-mounted eye-tracker while the surgeons performed a laparoscopic procedure on a virtual reality trainer. Blink frequency and duration were computed using computer vision technology. The level of workload experienced during the procedure was reported by surgeons using the NASA TLX. RESULTS: A total of 42 valid videos were recorded from 23 surgeons. After blinks were computed, videos were divided into two groups based on the blink frequency: infrequent group (≤ 6 blinks/min) and frequent group (more than 6 blinks/min). Surgical performance (measured by task time and trajectories of tool tips) was not significantly different between these two groups, but NASA TLX scores were significantly different. Surgeons who blinked infrequently reported a higher level of frustration (46 vs. 34, P = 0.047) and higher overall level of workload (57 vs. 47, P = 0.045) than those who blinked more frequently. The correlation coefficients (Pearson test) between NASA TLX and the blink frequency and duration were -0.17 and 0.446. CONCLUSION: Reduction of blink frequency and shorter blink duration matched the increasing level of mental workload reported by surgeons. The value of using eye-tracking technology for assessment of surgeon mental workload was shown.

Laparoscopic management of gastrointestinal stromal tumours: review at a Canadian centre.

BACKGROUND: Laparoscopic wedge resection has been widely accepted for small benign gastric tumours. Large gastrointestinal stromal tumours (GISTs), however, can be difficult to manipulate laparoscopically and are at risk for capsule disruption, which can then result in peritoneal seeding. Some authors have suggested that large GISTs (> 8 cm) are best approached using an open technique. However, there has been no consensus as to what the cut-off size should be. We conducted one of the largest Canadian series to date to assess outcomes and follow-up of the laparoscopic management of GISTs. METHODS: All patients with gastric GISTs presenting to Vancouver General Hospital and University of British Columbia Hospital between 2000 and 2008 were reviewed. Most lesions were resected using a wedge technique with closure of the stomach facilitated by an endoscopic linear stapling device. RESULTS: In all, 23 patients presented with GISTs; 19 patients underwent laparoscopic resection and, of these, 15 had a purely laparoscopic operation and 4 had a hand-assisted laparoscopic resection. Mean tumour size was 3.2 cm, with the largest tumour measuring 6.8 cm. There were no episodes of tumour rupture or spillage and no major intraoperative complications. All margins were negative. Mean follow-up was 13.3 (range 1-78) months. There was no evidence of recurrence or metastasis. CONCLUSION: The laparoscopic management of gastric GISTs is safe and effective with short hospital stays and good results over a mean follow-up of 13.3 months. We believe that it should be the preferred technique offered to patients.

Objective assessment of laparoscopic skills: dual-task approach.

BACKGROUND: Assessment of surgical performance is often accomplished with traditional methods that often provide only subjective data. Trainees who perform well on a simulator in a controlled environment may not perform well in a real operating room environment with distractions. This project uses the ideas of dual-task methodology and applies them to the assessment of performance of laparoscopic surgical skills. The level of performance on distracting secondary tasks while trying to perform a primary task becomes an indirect but objective measure of the surgical skill of the trainee. METHODS: Nine surgery residents and 6 experienced laparoscopic surgeons performed 3 primary tasks on a laparoscopic virtual reality simulator (camera position, grasping, and cholecystectomy) while being distracted by 3 secondary tasks (counting beeps, selective responses, and mental arithmetic). Completion time and error rates were recorded for each combination of tasks. RESULTS: When performed separately, time to completion and error rates for primary and secondary tasks were similar for learners and experts. When performing the tasks simultaneously, learners had more errors than experts. Error rates increased for learners when distracting tasks became more difficult or required more attention. Expert surgeons maintained consistent error rates despite the increasing difficulty of task combinations. CONCLUSIONS: The use of dual-task methodology may help trainers to identify which surgical trainees require more preparation before entering the real operating room environment. Expert surgeons are capable of maintaining performance levels on a primary task in the face of distractions that may occur in the operating room.

Kaposi sarcoma of the adrenal gland resembling epithelioid angiosarcoma: a case report.

Patients with human immunodeficiency virus infection are known to have increased risk of various neoplasms, including Kaposi sarcoma, which classically involves the skin and mucosal locations. The anaplastic variant of Kaposi sarcoma is rare and poorly documented in the literature. It is characterised clinically by a more aggressive behaviour and increased metastatic potential, and histologically by increased cellularity, mitotic rate, and rarely by epithelioid angiosarcoma-like morphology. We report herein a 64-year-old man with a long-standing history of human immunodeficiency virus infection who developed a right adrenal tumor with a high-grade anaplastic angiosarcoma-like morphology. Immunohistochemistry for human herpes virus-8 was strongly positive in the tumor cells. To the best of our knowledge, this is the first report of an anaplastic Kaposi sarcoma in the adrenal gland.

Surgeon's vigilance in the operating room.

OBJECTIVE: Surgeons' vigilance regarding patient condition was assessed using eye-tracking techniques during a simulated laparoscopic procedure. METHODS: Surgeons were required to perform a partial cholecystectomy in a virtual reality trainer (SurgicalSim; METI Inc, Sarasota, FL) while wearing a lightweight head-mounted eye-tracker (Locarna systems Inc, Victoria, British Columbia, Canada). Half of the patients were preprogrammed to present a mildly unstable cardiac condition during the procedure. Surgical performance (evaluated by task time, instrument trajectory, and errors), mental workload (by the National Aeronautics and Space Administration Task Load Index), and eye movement were recorded and compared between 13 experienced and 10 novice surgeons. RESULTS: Experienced surgeons took longer to complete the task and also made more errors. The overall workload reported by surgeons was similar, but expert surgeons reported a higher level of frustration and a lower level of physical demands. Surgeon workload was greater when operating on the unstable patient than on the stable patient. Novices performed faster but focused more of their attention on the surgical task. In contrast, experts glanced more frequently at the anesthetic monitor. CONCLUSIONS: This study shows the usefulness of using eye-tracking technology to measure a surgeon's vigilance during an operation. Eye-tracking observations can lead to inferences about a surgeon's behavior for patient safety. The unsatisfactory performance of expert surgeons on the VR simulator suggests that the fidelity of the virtual simulator needs to improve to enable surgeons to transfer their clinical skills. This, in turn, suggests using caution when having clinical experts as instructors to teach skills with virtual simulators.

Quantifying surgeon's contribution to team effectiveness on a mixed team with a junior surgeon.

BACKGROUND: A surgical team often consists of an experienced surgeon and surgeons in training. This project quantified the contribution of the experienced surgeon to the teamwork in a team comprised of 1 experienced and 1 novice surgeon (Mixed Team). METHODS: An experienced and a novice surgeon in a Mixed Team were required to complete a peg transportation task and an intracorporeal suture task collaboratively. Tasks were evaluated by a summative score (up to 100 points) that was calculated on task speed and accuracy. Performances of 24 Mixed Teams were compared to 24 Novice Teams (each composed of 2 novices) and 8 Expert Teams (each composed of 2 experienced surgeons). RESULTS: The Mixed Teams performed better (67.6 points) than the Novice Teams (51.3; P < .001) but worse than the Expert Teams (88.3; P < .001). When examining individual performance in the Mixed Teams, we observed that experienced surgeons maintained their superior performance like they did in the Expert Teams (P = .153). Novices in the Mixed Teams, however, showed markedly better performances than they did in the Novice Teams (P = .024). CONCLUSION: Instant guidance and instruction from experienced surgeons inspire novices' performance, providing a foundation for surgical teamwork effectiveness.

Hand-assisted laparoscopic splenectomy versus open splenectomy for massive splenomegaly: 20-year experience at a Canadian centre.

BACKGROUND: Multiple techniques for splenectomy are now employed and include open, laparoscopic and hand-assisted laparoscopic splenectomy (HALS). Concerns regarding a purely laparoscopic splenectomy for massive splenomegaly (> 20 cm) arise from potentially longer operative times, higher conversion rates and increased blood loss. The HALS technique offers the potential advantages of laparoscopy, with the added safety of having the surgeon's hand in the abdomen during the operation. In this study, we compared the HALS technique to standard open splenectomy for the management of massive splenomegaly. METHODS: We reviewed all splenectomies performed at 5 hospitals in the greater Vancouver area between 1988 and 2007 for multiple demographic and outcome measures. Open splenectomies were compared with HALS procedures for spleens larger than 20 cm. Splenectomy reports without data on spleen size were excluded from the analysis. We performed Student t tests and Pearson χ(2) statistical analyses. RESULTS: A total of 217 splenectomies were analyzed. Of these, 39 splenectomies were performed for spleens larger than 20 cm. We compared the open splenectomy group (19 patients) with the HALS group (20 patients). There was a 5% conversion rate in the HALS group. Estimated blood loss (375 mL v. 935 mL, p = 0.08) and the mean (and standard deviation [SD]) transfusion rates (0.0 [SD 0.0] units v. 0.8 [SD 1.7] units, p = 0.06) were lower in the HALS group. Length of stay in hospital was significantly shorter in the HALS group (4.2 v. 8.9 d, p = 0.001). Complication rates were similar in both groups. CONCLUSION: Hand-assisted laparoscopic splenectomy is a safe and effective technique for the management of spleens larger than 20 cm. The technique results in shorter hospital stays, and it is a good alternative to open splenectomy when treating patients with massive splenomegaly.

Maintaining forward view of the surgical site for best endoscopic practice.

Endoscopic surgery performed through patients' natural orifices (NOTES procedures) often require some degree of retroflexion of the operating system. This can cause a misalignment between the displayed image and the actual work plane, leading to performance difficulties. This study investigated the impact of retroflexion on task performance in a simulated environment. Surgeons were required to perform an aiming and pointing task under two experimental conditions: forward-view vs. retroflexed-view. Results showed that both expert and novice surgeons required significantly longer time for completing the task when the scope was retroflexed, compared to when the scope faced forwards. Results address the importance of careful selection of the surgical approach to avoid image retroflexion. Further analysis revealed that the novices were more vulnerable than experts to image distortion with the retroflexed view. This addresses the necessity for surgeons to go through extensive endoscopic training to overcome the visual-motor challenges before they can perform NOTES procedures safely and effectively.

An appendiceal neoplastic lesion: case report and implications for colonoscopic screening and surveillance.

A 65-year-old man with a history of previously resected colonic adenomas had an apparent cecal lesion detected during colonoscopy. The polyp proved to be a tubulovillous adenoma with high-grade dysplasia involving most of the body of the appendix along with the base of the cecum. The appendiceal mucosa is biologically similar to the colonic mucosa, yet remains relatively 'hidden' in screening and surveillance studies, which suggests important implications for evolving detection strategies in the follow-up of patients with a previous colon polyp or cancer resections. Although endoscopic removal of the appendix has been reported, treatment of these localized appendiceal lesions requires a wide surgical excision.

Perioperative analysis of laparoscopic versus open liver resection.

BACKGROUND: Over the past decade there has been an increasing trend toward minimally invasive liver surgery. Initially limited by technical challenges, advances in laparoscopic techniques have rendered this approach safe and feasible. However, as health care costs approach 50% of some provincial budgets, surgical innovation must be justifiable in costs and patient outcomes. With introduction of standardized postoperative liver resection guidelines to optimize patient hospital length of stay, the advantages of laparoscopic liver resection (LLR) compared with open liver resection (OLR) measured by perioperative outcomes and resource utilization are not well defined. It remains to be established whether LLR is superior to OLR by these measurements. METHODS: Eighteen LLRs performed at the Vancouver General Hospital from 2005 to 2007 were prospectively analyzed. These data were compared with an equivalent group of 12 consecutive OLRs undertaken immediately prior to the introduction of LLR. Outcomes were evaluated for differences in perioperative morbidity, hospital length of stay, and operative costs. RESULTS: There were no differences between LLRs and OLRs in demographics, pathology, cirrhosis, tumour location or extent of resection. There were no deaths. LLRs had significantly decreased intraoperative blood loss (287 ml versus 473 ml, p = 0.03), postoperative complications (6% versus 42%, p = 0.03), and length of stay (4.3 versus 5.8 days, p = 0.01) compared with OLRs. There were no differences in operating time for LLRs compared to OLRs (135 min versus 138 min, respectively), total time in the operating theatre (214 min versus 224 min), or costs related to stapler/trocar devices (CA $1267 versus CA $1007). CONCLUSIONS: LLR is associated with decreased morbidity and decreased resource utilization compared with OLR. Perioperative patient outcomes and cost-effectiveness justify LLR despite introduction of standardized postoperative liver resection guidelines and decreased length of stay for OLR.