Sleep deprivation among surgical residents: Does it affect performance while practising a laparoscopic intestinal anastomosis?

INTRODUCTION: To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. METHODS: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. RESULTS: 402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters. CONCLUSIONS: Fatigue increases the risk of leakage and the time to do the exercise.

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training. / Análisis de los estilos de aprendizaje en un curso de habilidades técnicas laparoscópicas. Implicaciones para el entrenamiento quirúrgico.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Development and Validation of a Tool for the Evaluation of Laparoscopic Intestinal Anastomosis in Simulation. / Desarrollo y validación de una herramienta para la evaluación de la anastomosis intestinal laparoscópica en simulación.

INTRODUCTION: Laparoscopic side-to-side intestinal anastomosis is a common in clinic practice and training simulation. The aim of this study is to design and validate a reliable and reproducible tool for its evaluation. METHODS: A modified Delphi method was used to design a tool with elements that determine quality, including 5 items: separation between stiches, eversion, tension, leak and iatrogenesis. The study included 21 participants (10 first-year residents and 11 experts) who performed a 5cm laparoscopic intestinal side-to-side anastomosis with porcine viscera. The evaluations were blinded and done independently by 2 evaluators. RESULTS: The means obtained by novice and expert participants were, respectively: separation between stiches 3.2 vs. 5.7 (P < .001), eversion 3.3 vs. 5.9 (P = .004), tension 2.9 vs. 5.9 (P = .001), leak tightness 3.2 vs. 5.7 (P = .005), iatrogenesis 6.9 vs. 7 (P = .47). The iatrogenesis parameter was not discriminatory, so it was removed from the tool. The total results were 12.5 for novices and 23.2 for experts (P = .001). The correlation between observers presented an intraclass correlation coefficient of 0.99 for the separation between stiches, 0.94 for eversion, 0.98 for tension and 0.99 for leak. The correlation between the score and the leak without pressure presented a Rosenthal's R of -0.71 (P < .001); with pressure R = -0.55 (P = .01). CONCLUSIONS: The designed tool is valid to discriminate between novice and expert participants, presents very high concordance between observers and correlates with the risk of leak.

Simulation as a surgical teaching model. / La simulación como modelo de enseñanza en cirugía.

Teaching of surgery has been affected by many factors over the last years, such as the reduction of working hours, the optimization of the use of the operating room or patient safety. Traditional teaching methodology fails to reduce the impact of these factors on surgeons training. Simulation as a teaching model minimizes such impact, and is more effective than traditional teaching methods for integrating knowledge and clinical-surgical skills. Simulation complements clinical assistance with training, creating a safe learning environment where patient safety is not affected, and ethical or legal conflicts are avoided. Simulation uses learning methodologies that allow teaching individualization, adapting it to the learning needs of each student. It also allows training of all kinds of technical, cognitive or behavioural skills.

Learning curve patterns generated by a training method for laparoscopic small bowel anastomosis.

BACKGROUND: The identification of developmental curve patterns generated by a simulation-based educational method and the variables that can accelerate the learning process will result in cost-effective training. This study describes the learning curves of a simulation-based instructional design (ID) that uses ex vivo animal models to teach laparoscopic latero-lateral small bowel anastomosis. METHODS: Twenty general surgery residents were evaluated on their performance of laparoscopic latero-lateral jejuno-jejunal anastomoses (JJA) and gastro-jejunal anastomoses (GJA), using swine small bowel and stomach on an endotrainer. The ID included the following steps: (1) provision of references and videos demonstrating the surgical technique, (2) creation of an engaging context for learning, (3) critical review of the literature and video on the procedures, (4) demonstration of the critical steps, (5) hands-on practice, (6) in-action instructor's feedback, (7) quality assessment, (8) debriefing at the end of the session, and (9) deliberate and repetitive practice. Time was recorded from the beginning to the completion of the procedure, along with the presence or absence of anastomotic leaks. RESULTS: The participants needed to perform 23.8 ± 6.96 GJA (12-35) and 24.2 ± 6.96 JJA (9-43) to attain proficiency. The starting point of the learning curve was higher for the GJA than for the JJA, although the slope and plateau were parallel. Further, four types of learning curves were identified: (1) exponential, (2) rapid, (3) slow, and (4) no tendency. The type of pattern could be predicted after procedure number 8. CONCLUSIONS: These findings may help to identify the learning curve of a trainee early in the developmental process, estimate the number of sessions required to reach a performance goal, determine a trainee's readiness to practice the procedure on patients, and identify the subjects who lack the innate technical abilities. It may help motivated individuals to become reflective and self-regulated learners. Moreover, the standardization of the ID may help to measure the effectiveness of learning strategies and make comparisons with other educational strategies.

[Initial results of robotic esophagectomy for esophageal cancer]. / Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago.

INTRODUCTION: There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS: Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS: Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS: Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

[Transanal endoscopic operations for rectal tumours]. / Cirugía endoscópica transanal en tumores rectales.

BACKGROUND: Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity. METHODS: In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…). RESULTS: The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients. CONCLUSIONS: TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.

[Surgical resident training program in minimally invasive surgery experimental laboratory (CENDOS)]. / Programa de formación del residente de cirugía en un laboratorio experimental de cirugía minimamente invasiva (CENDOS).

INTRODUCTION: The rapid development of laparoscopic surgery makes resident training programmes necessary. OBJECTIVE: To analyse the results of a structured programme of laparoscopic training in an experimental laboratory. MATERIAL AND METHOD: From 2003 until 2007, we trained 11 general surgery residents for 20 h every 3 months, for three years. The practice consisted of suture and anastomosis in Endo-Trainer with animal organs, as well as laparoscopic techniques in live animals. In the Endo-Trainer practice we evaluated the time and quality of anastomosis performance. In laparoscopic techniques (cholecystectomy and anti-reflux surgery) a task table was evaluated, from 0 (no errors) to 100 (severe lesion). RESULTS: In total, 314 anastomosis were performed by the 11 residents, with a median of 28.5 per resident (24-42). The mean time for the first gastro-jejunal anastomosis was 135 min (100-140) and 65 min (57.5-105) for the first jejunal-jejunal anastomosis. Maximum learning was achieved after 45 training hours. There were no appreciable differences between both types of anastomosis. There was inadequate anastomosis quality due to leakage in 17.1% during the learning period and 13.7% during the consolidation period. In the animal, 172 procedures were performed. In cholecystectomy and anti-reflux surgery the mean scores were 2.4 and 5.6 points, respectively. In the remaining procedures, subjectively evaluated by the monitors, the quality was adequate in 65%, deficient in 22% and highly deficient in 13%. CONCLUSIONS: This structured programme of laparoscopic skills based on intestinal anastomosis allows for quicker resident training.