Laparoscopy and thoracoscopy in small animal surgery: A 2020 survey of small animal diplomate and resident veterinary surgeons.

OBJECTIVE: To document the utilization and training of laparoscopic and thoracoscopic minimally invasive surgery (MIS) techniques within the American, European, Australian and New Zealand Colleges of Small Animal Veterinary Surgeons (ACVS, ECVS, and ANZCVS) in 2020. STUDY DESIGN: Observational study. SAMPLE POPULATION: Diplomates and residents of the ACVS, ECVS, and FANZCVS. METHODS: An electronic survey was sent using veterinary list servers. Questions were organized into categories evaluating (1) the demographics of the study population and the caseload, (2) comfort level with specific procedures, (3) motivating factors and limitations, and (4) surgical training and the role of the governing bodies. RESULTS: Respondents included 111 practicing surgeons and 28 residents. Respondents' soft-tissue MIS caseloads had increased since they first started performing MIS; however, most respondents were only comfortable performing basic laparoscopy. Over half of the respondents agreed on the patient benefits and high standard of care provided by MIS. Perceived adequate soft-tissue training in MIS during residency was strongly associated with perceived proficiency at the time of survey response. Most respondents agreed that the specialty colleges should take a more active role in developing standards for soft-tissue MIS, with residents agreeing that a required standardized course would be beneficial. CONCLUSION: Soft-tissue MIS is widely performed by diplomates and residents. Perceived adequate soft-tissue MIS training was strongly associated with perceived proficiency. CLINICAL SIGNIFICANCE: There is substantial underutilization of advanced MIS techniques in veterinary specialty surgical practice, which might be improved by a stronger focus on MIS training during residency.

Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework.

Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined.

[Thoracoscopic Surgery].

Thoracoscopic devices have become essential in general thoracic surgery. In the past 30 years, many reports about thoracoscopic surgery have expanded the indications to include malignant neoplasms. Various optional procedures including uniportal, non-intubated, robotic, and needlescopic techniques have been developed and more than 70% of lung cancer operations are currently performed using thoracoscopy in Japan. Although there are many choices for minimally invasive surgery, the long-term outcome of these options remains unclear. In addition, training systems for younger surgeons have not provided exposure to novel optional methods, as there are few high-volume centers in Japan.

Short-term outcomes and one surgeon's learning curve for thoracoscopic esophagectomy performed with the patient in the prone position.

PURPOSE: Thoracoscopic esophagectomy with the patient in the prone position (TEP) is now being performed as minimally invasive esophagectomy for esophageal cancer. This study examines the short-term outcomes and the learning curve associated with TEP. METHODS: One surgeon ("Surgeon A") performed TEP on 100 consecutive patients assigned to three periods based on treatment order. Each group consisted of 33 or 34 patients. The outcomes of the three groups were compared to define the influence of surgeon expertise. RESULTS: Outcomes improved as Surgeon A gained experience in performing this operation, as evidenced by reduced thoracic operative times between periods 1 and 2, and then between periods 2 and 3 (p = 0.0033 and p = 0.0326, respectively); an increased number of retrieved chest nodes between periods 1 and 2 (p = 0.0070); and a decline in recurrent laryngeal nerve (RLN) palsy between periods 2 and 3 (p = 0.0450). Period 2 was the pivotal period for each learning curve. CONCLUSIONS: An individual surgeon's learning curve over the course of 100 TEP procedures had three outcomes: a shortened operative time, a higher number of retrieved chest nodes, and a decreased rate of RLN palsy. Approximately 30-60 cases were needed to reach a plateau in the TEP procedure and a reduction in the morbidity rate.

Simulation training using cadaver sheep chest in pleuroscopy - A step towards skills enhancement.

OBJECTIVE: For assessing the use of if simulation training on animal cadavers as a useful tool for training in pleuroscopy. METHODS: The email-based cross-sectional study was conducted in December 2014 at Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore, Pakistan, and comprised respiratory physicians and trainees after their participation in a two-day hands-on training course on pleuroscopy and pleural medical procedures. The responses were analysed and the responses of physicians and trainees were compared. RESULTS: Of the 44 individuals who attended the course and were contacted through emails, 38(86.4%) responded, including 20(52.6%) physicians and 18(47.3%) trainees. All the 38(100%) subjects uniformly accepted the utility of simulation training in enhancing education, improving skill, and improving confidence by repeated practice, and felt that the inclusion of animal models for learning fundamental pleuroscopic procedures can help a lot in teaching. CONCLUSIONS: Animal cadavers can be used as an effective teaching tool for pleuroscopy training.

Trainee competence in thoracoscopic esophagectomy in the prone position: evaluation using cumulative sum techniques.

PURPOSE: Minimally invasive esophagectomy (MIE) has less morbidity than the open approach. In particular, thoracoscopic esophagectomy in the prone position (TEP) has been performed worldwide. Using the cumulative sum control chart (CUSUM) method, this study aimed to confirm whether a trainee surgeon who learned established standards would become skilled in TEP with a shorter learning curve than that of the mentoring surgeon. METHODS: Surgeon A performed TEP in 100 patients; the first 22 patients comprised period 1. His learning curve, defined based on the operation time (OT) of the thoracic procedure, was evaluated using the CUSUM method, and short-term outcomes were assessed. Another 22 patients underwent TEP performed by surgeon B, with outcomes compared to those of surgeon A's period 1. RESULTS: Using the CUSUM chart, the peak point of the thoracic procedure OT occurred at the 44th case in surgeon A's experience of 100 cases. With surgeon A's first 22 cases (period 1), the peak point of the thoracic procedure OT could not be confirmed and graph is expanding soaring at CUSUM chart. The CUSUM chart of surgeon B's experience of 22 cases clearly indicated that the peak point of the thoracic procedure OT occurred at the 17th case. The rate of recurrent laryngeal nerve palsy for surgeon B (9 %) was significantly lower than for surgeon A in period 1 (36 %) (p = 0.0266). CONCLUSIONS: There is some possibility for a trainee surgeon to attain the required basic skills to perform TEP in a relatively short period of time using a standardized procedure developed by a mentoring surgeon. The CUSUM method should be useful in evaluating trainee competence during an initial series of procedures, by assessing the learning curve defined by OT.

Quantitative pediatric surgical skill assessment using a rapid-prototyped chest model.

INTRODUCTION: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed. MATERIAL AND METHODS: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup. RESULTS: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model. CONCLUSION: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Simulation-based training for thoracoscopic lobectomy: a randomized controlled trial: virtual-reality versus black-box simulation.

BACKGROUND: Video-assisted thoracic surgery is gradually replacing conventional open thoracotomy as the method of choice for the treatment of early-stage non-small cell lung cancers, and thoracic surgical trainees must learn and master this technique. Simulation-based training could help trainees overcome the first part of the learning curve, but no virtual-reality simulators for thoracoscopy are commercially available. This study aimed to investigate whether training on a laparoscopic simulator enables trainees to perform a thoracoscopic lobectomy. METHODS: Twenty-eight surgical residents were randomized to either virtual-reality training on a nephrectomy module or traditional black-box simulator training. After a retention period they performed a thoracoscopic lobectomy on a porcine model and their performance was scored using a previously validated assessment tool. RESULTS: The groups did not differ in age or gender. All participants were able to complete the lobectomy. The performance of the black-box group was significantly faster during the test scenario than the virtual-reality group: 26.6 min (SD 6.7 min) versus 32.7 min (SD 7.5 min). No difference existed between the two groups when comparing bleeding and anatomical and non-anatomical errors. CONCLUSION: Simulation-based training and targeted instructions enabled the trainees to perform a simulated thoracoscopic lobectomy. Traditional black-box training was more effective than virtual-reality laparoscopy training. Thus, a dedicated simulator for thoracoscopy should be available before establishing systematic virtual-reality training programs for trainees in thoracic surgery.

Learning thoracoscopic lobectomy in resident training.

BACKGROUND: Thoracoscopic lobectomy is a safe and effective procedure; however, the ways by which to incorporate this technically demanding procedure into residency training is still unknown. We reported on the outcomes of thoracoscopic lobectomies performed by a single thoracic resident, who was simultaneously undergoing training for both open and thoracoscopic lobectomies. PATIENTS AND METHODS: Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies that were performed by a trainee surgeon (B.-Y.W.) were prospectively obtained. Data were grouped into the first 30 and subsequent 57 cases. Patient characteristics, operative data, complications, and surgical pathology were analyzed. RESULTS: The mean operating time in group 2 was significantly lower compared with group 1 (264.0 ± 45.9 min in group 1 vs. 197.5 ± 57.7 min in group 2; p<0.001). There were no mortalities in both the groups and no significant differences in postoperative complications. CONCLUSIONS: Thoracoscopic lobectomy can be taught to a nonexperienced thoracic resident during an open procedure without compromising the safety of patients. It appears that surgical performance reaches a plateau after the completion of 30 cases.

Design and development of a novel thoracoscopic tracheoesophageal fistula repair simulator.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) is a technically challenging surgical procedure. This congenital anomaly is rare; therefore, training opportunities for surgical trainees are limited. There are currently no validated simulation tools available to help train pediatric surgery trainees. The simulator that was developed is a low-cost, reusable model. It simulates the right side of a term neonate chest and contains a tissue block that has been surgically modified to replicate the anatomy of EA/TEF.

Esophageal Magnetic Anastomosis Device (EMAD) to Simplify and Improve Outcome of Thoracoscopic Repair for Esophageal Atresia with Tracheoesophageal Fistula: A Proof of Concept Study.

BACKGROUND: We designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy. METHODS: Synthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students (n = 10) and surgical trainees (n = 10) were asked to perform thoracoscopic repair of an "EA" with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3-4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5-3 kg) esophagi (n = 25 in each test series). BP and PF were measured and compared against each other. RESULTS: Medical students were unable to complete HA, but were successful with the EMAD in 11.1 ± 2.78 min. Surgical trainees completed EMA in 4.6 ± 2.06 min vs. HA 30.8 ± 4.29 min (p<0.001). The BP following a HA (14.1 ± 3.32 cmH2O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH2O), whereas the BP with the EMAD was extremely high (>90 cmH2O) (p<0.001). The PF of an EMA (1.8 ± 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 ± 0.43 N) (p<0.0001). CONCLUSION: The EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation.

Advanced interventional pulmonology procedures: training guidelines from the Thoracic Society of Australia and New Zealand.

Training in interventional pulmonology procedures is increasing in popularity. However, the nature of training is difficult to define, particularly with respect to an adequate number of cases. These guidelines approach training not just from a modest number of supervised cases, but also from a range of educational and outcome targets which give a rounded approach to the issue. These include prerequisite skills from basic procedures, the place of simulated training, formal simulation testing, modest procedural outcome and side effect targets, audit presentations, ongoing reading, and hands-on training expectations. All of this would still be under the supervision of an experienced trainer.

The role of motion tracking in assessing technical skill acquisition using a neonatal 3D-printed thoracoscopic esophageal atresia/tracheo-esophageal fistula simulator.

INTRODUCTION: Acquiring the technical skills required for thoracoscopic repair of esophageal atresia with tracheo-esophageal fistula (EA/TEF) is challenging. A high-fidelity 3D-printed pediatric thoracoscopic EA/TEF simulator has been developed to address this issue. This study explored motion-tracking as an assessment tool to distinguish between surgeons of different expertise using the simulator. METHODS: Participants performed a single intracorporeal suture between the esophageal ends in EA with TEF. Total relative path lengths of the right and left surgical instruments were recorded during the task. Each video-recorded attempt was assessed by a blinded pediatric surgeon using a modified Objective Structured Assessment of Technical Skills (OSATS) score. Data recorded as median (range) and statistical significance as p<0.05. RESULTS: The task was performed by 17 participants. The median OSATS scores identified a significant difference between experts and novices. A difference between left- and right-hands was only found in the mid-skill level group. Right-hand path length was greatest in novices and lowest in experts. Left-hand path length was greatest in novices and the mid-skill level group compared to experts. CONCLUSION: Experts had the lowest total path length for either hand, suggesting they had the greatest efficiency of movement. The similar high path lengths in both hands for novices indicate their relatively low level of skill with either hand. The difference between right- and left-hand path lengths in the mid-skill level group likely reflects the improved right-handed technical skills in contrast to the still developing left hand. Further focus on the left hand during simulation training may improve left-handed economy of movement.

New challenges in medical thoracoscopy.

Thoracoscopy is currently the gold standard for the diagnosis and treatment of pleural diseases. Its diagnostic yield is 95% in patients with malignant pleural disease, with approximately 90% successful pleurodesis for malignant pleural effusion and 95% for pneumothorax. At the same time, thoracoscopy constitutes an important tool in the research of pleural pathophysiology and molecular biology. The improvement of technology has provided important tools to thoracoscopy, such as autofluorescence, narrow band imaging, and infrared light, used in clinical and basic research in many disorders involving the pleura. For these reasons, training in thoracoscopy should be considered equally important as training in bronchoscopy for residents in respiratory medicine.

Use of competency-based metrics to determine effectiveness of a postgraduate thoracoscopy course.

BACKGROUND: Despite the paradigm shift from process to competency-based education, no study has explored how competency-based metrics might be used to assess short-term effectiveness of thoracoscopy-related postgraduate medical education. OBJECTIVES: To assess the use of a single-group, pre-/post-test model comprised of multiple-choice questions (MCQ) and psychomotor skill measures to ascertain the effectiveness of a postgraduate thoracoscopy program. METHODS: A 37-item MCQ test of cognitive knowledge was administered to 17 chest physicians before and after a 2-day continued medical education-approved program. Pre- and post-course technical skills were assessed using rigid videothoracoscopy simulation stations. Competency-based metrics (mean relative gain, mean absolute gain, and class-average normalized gain ) were calculated. A >30% was used to determine curricular effectiveness. RESULTS: Mean cognitive knowledge score improved significantly from 20.9 to 28.7 (7.8 ± 1.3 points, p < 0.001), representing a relative gain of 37% and an absolute gain of 21%. Mean technical skill score improved significantly from 5.20 to 7.82 (2.62 ± 0.33 points, p < 0.001), representing a relative gain of 50% and an absolute gain of 33%. Non-parametric testing confirmed t test results (p < 0.001). Class-average normalized gains were 48 and 92%, respectively. CONCLUSION: Competency-based metrics, including class-average normalized gain, can be used to assess course effectiveness and to determine if a program meets predesignated objectives of knowledge acquisition and psychomotor technical skill.

Development of an instrumented thoracoscopic surgical trainer for objective evaluation of esophageal atresia/tracheoesophageal fistula repair.

Operative repair of complex conditions such as esophageal atresia and tracheoesophageal fistula (EA/TEF) is technically demanding, but few training opportunities exist outside the operating theater for surgeons to attain these skills. Learning them during surgery on actual neonates where the stakes are high, margins for error narrow, and where outcomes are influenced by technical expertise, is problematic. There is an increasing demand for high-fidelity simulation that can objectively measure performance. We developed such a simulator to measure force and motion reliably, allowing quantitative feedback of technical skill. A 3D-printed simulator for thoracoscopic repair of EA/TEF was instrumented with motion and force tracking components. A 3D mouse, inertial measurement unit (IMU), and optical sensor that captured force and motion data in four degrees of freedom (DOF) were calibrated and verified for accuracy. The 3D mouse had low average relative errors of 2.81%, 3.15%, and 6.15% for 0 mm, 10 mm offset in Y, and 10 mm offset in X, respectively. This increased to - 23.5% at an offset of 42 mm. The optical sensors and IMU displayed high precision and accuracy with low SDs and average relative errors, respectively. These parameters can be a useful measurement of performance for thoracoscopic EA/TEF simulation prior to surgery. Graphical abstract Inclusion of sensors into a high-fidelity simulator design can produce quantitative feedback which can be used to objectively asses performance of a technically difficult procedure. As a result, more surgical training can be done prior to operating on actual patients in the operating theater.

The Current Thoracoscopic Management of Esophageal Atresia.

The thoracoscopic repair of esophageal atresia with tracheoesophageal fistula is a complex neonatal minimally invasive procedure. The thoracoscopic approach is now nearing its third decade of experience and but is overall still not widely utilized, only in skilled centers and by experienced surgeons. This article will summarize the recent advancements in technique and knowledge in the thoracoscopic approach to this challenging neonatal congenital abnormality.

A novel cervical esophagogastric anastomosis simulator.

OBJECTIVES: At least partially technically related, a cervical esophagogastric anastomosis has a 12% to 14% leak rate, which is theoretically reducible with simulator practice. Preliminary development and testing of a cervical esophagogastric anastomosis simulator are described. METHODS: A portable, low-cost, scale reproduction of the cervical esophagogastric anastomosis operative site was engineered around a 19 × 11 × 6-cm plastic box. Silicone "esophageal" and "gastric tip" castings permitted construction of a stapled side-to-side cervical esophagogastric anastomosis guided by an illustrated curriculum. In a 2-phase pilot study, the simulator and curriculum were evaluated. Phase 1: Seven faculty evaluated fidelity using a 5-point, 24-item survey of (1) physical attributes, (2) realism of materials, (3) realism of experience, (4) value, and (5) relevance, and (6) ability to perform tasks. Overall impression of the simulator was also measured. Phase 2: Eight thoracic surgical trainees similarly evaluated the simulator and the quality of the curriculum. Faculty and trainee ratings were compared using a Rasch model, and inter-rater agreement was estimated. RESULTS: There were no overall fidelity differences across faculty and resident ratings. Combined observed averages ranged from 4.52 (Realism of Materials) to 5.00 (Relevance). Lifelike feel of esophagus had the lowest ratings (observed average = 4.40). Residents rated interrupted outer layer of anterior closure to be more difficult (observed average = 4.13) than faculty (observed average = 4.86; P = .016, d = 1.99). Global ratings (observed average = 3.33/4.00) indicated participants believed the simulator could be used for cervical esophagogastric anastomosis training now, but could be improved slightly. CONCLUSIONS: Preliminary evidence suggests the novel cervical esophagogastric anastomosis simulator is valuable as a surgical training tool.

Simultaneous Two-Dimensional and Three-Dimensional Simulation of Thoracoscopic Sleeve Lobectomy: A Quick Understanding of Pitfalls.

Thoracoscopic sleeve lobectomy is challenging, considering the technical difficulty in controlling the needle angle and thread through the port. However, effective simulation of the procedure remains to be established. Here, we describe our first experience with thoracoscopic sleeve lobectomy simulation using a three-dimensional printed thoracic model and a handmade rolled sponge. Owing to the transparent structure, we could simultaneously confirm the suturing technique through the monitor (two-dimensional) and direct vision (three-dimensional). We are certain that our realistic and easily repeatable simulation will assist in developing better technique and conduct feasible thoracoscopic sleeve lobectomy.

Critical design and validation considerations for the development of neonatal minimally invasive surgery simulators.

BACKGROUND/PURPOSE: Pediatric surgical trainees have limited exposure to advanced minimally invasive surgery (MIS) during their clinical training, particularly for cases such as esophageal atresia/tracheoesophageal fistula (EA/TEF). Simulation on validated neonatal models offers an alternative means of training that may augment traditional forms of training; but to be useful, they must fulfill certain criteria. METHODOLOGY: Review of the currently available MIS, thoracoscopic and laparoscopic, simulators for pediatric surgery, and identification of those factors that contribute to their fidelity and validity as a training tool that must be incorporated in the design of future simulation models. RESULTS: There are few neonatal laparoscopic and thoracoscopic models currently available, or in the research stage. To our knowledge, there is no commercially available, synthetic, high fidelity and low cost thoracoscopic model in existence. Use of animal tissue has disadvantages of ethical dilemmas, cost, and logistic and procurement issues. Newer synthetic models need to be validated for fidelity, to replicate those components of the operation that pose the greatest technical challenge, and incorporate means of measuring acquisition of technical expertise. CONCLUSION: This review describes the principles that need to be considered to develop low cost, validated high-fidelity MIS simulator that can be used for training, and that is capable of measuring the acquisition of the technical skills that can be applied to the repair of complex procedures such as esophageal atresia. Level of evidence III.