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BACKGROUND: The role of paramedics has expanded significantly over the past two decades, requiring advanced skills and education to meet the demands of diverse healthcare settings. In 2021, the academic requirements for paramedics were raised to a bachelor's degree to align with other registered professions. The limited evidence on effective paramedic practice education necessitates a novel or new examination of unique learning methods, emphasising the need to establish effective learning relationships between mentors and learners to enhance professional respect and support achieving learning outcomes. This study aimed to investigate expectations between student paramedics and their mentors, focusing on the learning dynamics within paramedic education. METHODS: This qualitative study used purposive sampling to recruit participants from two distinct cohorts: student paramedics from the University of Stirling and Practice Educator Mentors from the Scottish Ambulance Service. Focus groups were conducted to illuminate comprehensive insights into participants' expectations regarding practice education and their respective roles in the learning process. Codebook thematic analysis was used to assess the alignment of these expectations. RESULTS: Findings illustrate important challenges within practice placement across learning paradigms and highlight the attitudes surrounding the integration of higher education and expectations of practice placements. These challenges encompass systemic barriers, including the support provided to mentors as they assume increased responsibilities and barriers that deter qualified staff from initially undertaking this role. CONCLUSION: The study aimed to assess expectations between practice educators and students within the paramedic profession in Scotland. The methodology effectively identified key themes from comprehensive data, marking the first primary research in this field. There are disparities in learning styles, expectation measurement, and attitudes toward higher education during practice placements, which could significantly impact the teaching and assessment processes. The findings suggest increased support for practice educators, educational programs addressing challenges of mentorship, and stronger links between higher education institutes and the Scottish Ambulance Service. Further research is needed to understand the extent of the expectation gap, how expectations evolve, and to develop strategies to address disparities.
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Bacharelado em Enfermagem , Mentores , Humanos , Paramédico , Motivação , Estudantes , Bacharelado em Enfermagem/métodos , Pesquisa QualitativaRESUMO
PURPOSE: Laparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures. METHODS: All consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined. RESULTS: A total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072) CONCLUSION: Robotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.
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Colite Ulcerativa , Bolsas Cólicas , Laparoscopia , Proctocolectomia Restauradora , Procedimentos Cirúrgicos Robóticos , Humanos , Proctocolectomia Restauradora/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Pontuação de Propensão , Bolsas Cólicas/efeitos adversos , Colite Ulcerativa/cirurgia , Resultado do Tratamento , Laparoscopia/métodos , Anastomose Cirúrgica/métodos , Complicações Pós-Operatórias/etiologiaRESUMO
Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.
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Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Estomas Cirúrgicos , Humanos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Neoplasias Retais/cirurgia , Reto/cirurgia , Anastomose Cirúrgica , Fístula Anastomótica/prevenção & controle , Estudos RetrospectivosRESUMO
PURPOSE: Obesity, neoadjuvant-radiotherapy, tumour proximity to the anal verge and previous abdominal surgery are factors that might increase the intra-operative difficulty of laparoscopic rectal cancer surgery. However, whether patients with these 'high-risk' characteristics are subject to worse short- or long-term outcomes is debated. The aim of this study is to examine the short- and long-term clinical and oncological outcomes of patients receiving laparoscopic rectal surgery with any of these high-risk characteristics and compare them with patients that do not possess any of these high-risk features. METHODS: For the purpose of this study data from consecutive patients receiving laparoscopic rectal cancer resections between 2006 and 2016 from two centres were analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI ≥ 30, neoadjuvant chemoradiotherapy, tumour < 8 cm from the anal verge and previous abdominal surgery. RESULTS: A total of 313 patients were identified (227 high risk, 86 low risk). Short-term outcomes were similar between the two groups with the exception of blood loss and length of stay, which were higher in the high-risk group (10 vs 2.5 ml, p = 0.045; 7 vs 5 days, p = 0.001). There were no statistically significant differences in 5-year overall survival (79.7% vs 79.8%, p = 0.757), disease-free survival (76.8% vs 69.3%, p = 0.175), distant disease-free interval (84.8% vs 79.7%, p = 0.231) and local recurrence-free interval (100%, 97.4%, p = 0.162) between the two groups. CONCLUSION: Similar short- and long-term outcomes can be achieved in high-risk and low-risk patients receiving laparoscopic rectal surgery. The presented data support the suitability of laparoscopic surgery for this group of patients.
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Laparoscopia/efeitos adversos , Obesidade/complicações , Complicações Pós-Operatórias/epidemiologia , Neoplasias Retais/cirurgia , Idoso , Índice de Massa Corporal , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
The original version of this article unfortunately contained a mistake on the co-author name.
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PURPOSE: Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients. METHODS: All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined. RESULTS: A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033). CONCLUSIONS: In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.
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Laparoscopia , Obesidade/complicações , Neoplasias Retais/complicações , Neoplasias Retais/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: As obesity becomes more prevalent, it presents a technical challenge for minimally invasive colorectal resection surgery. Various studies have examined the clinical outcomes of obese surgical patients. However, morbidly obese patients (BMI ≥ 35) are becoming increasingly more common. This study aims to investigate the short-term surgical outcomes of morbidly obese patients undergoing minimal-invasive colorectal surgery and compare them with both obese (30 ≤ BMI < 35) and non-obese patients (BMI < 30). METHODS: Patients from three centres who received minimally invasive colorectal surgical resections between 2006 and 2016 were identified from prospectively collected databases. The baseline characteristics and surgical outcomes of morbidly obese, obese and non-obese patients were analysed. RESULTS: A total of 1386 patients were identified, 84 (6%) morbidly obese, 246 (18%) obese and 1056 (76%) non-obese. Patients' baseline characteristics were similar for age, operating surgeon, surgical approach but differed in terms of ASA grade and gender. There was no difference in conversion rate, length of stay, anastomotic leak rate and 30-day readmission, reoperation and mortality rates. Operation time and blood loss were different across the 3 groups (morbidly obese vs obese vs non-obese: 185 vs 188 vs 170 min, p = 0.000; 20 vs 20 vs 10 ml, p = 0.003). In patients with malignant disease there was no difference in lymph node yield or R0 clearance. Univariate and multivariate linear regression analysis showed that for every one-unit increase in BMI operative time increases by roughly 2 min (univariate 2.243, 95% CI 1.524-2.962; multivariate 2.295; 95% CI 1.554-3.036). Univariate and multivariate binary logistic regression analyses showed that BMI does not affect conversion or morbidity and mortality. CONCLUSIONS: The increased technical difficulty encountered in obese and morbidly obese patients in minimally invasive colorectal surgery results in higher operative times and blood loss, although this is not clinically significant. However, conversion rate and post-operative short-term outcomes are similar between morbidly obese, obese and non-obese patients.
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Índice de Massa Corporal , Colectomia/métodos , Doenças do Colo/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Obesidade Mórbida/complicações , Protectomia/métodos , Doenças Retais/cirurgia , Adulto , Idoso , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/etiologia , Estudos de Casos e Controles , Doenças do Colo/complicações , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/diagnóstico , Duração da Cirurgia , Doenças Retais/complicações , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: A structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM). METHODS: Prospectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons. RESULTS: Data from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20-20) ml and median length of stay 5 (IQR 4-8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi. CONCLUSIONS: Our results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.
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Adenocarcinoma/cirurgia , Educação/normas , Neoplasias Retais/cirurgia , Reto/cirurgia , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/normas , Adenocarcinoma/diagnóstico , Adenocarcinoma/terapia , Idoso , Competência Clínica , Terapia Combinada , Avaliação Educacional/métodos , Avaliação Educacional/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Portugal , Neoplasias Retais/diagnóstico , Neoplasias Retais/terapia , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Reino UnidoRESUMO
PURPOSE: Urological and sexual dysfunction are recognised risks of rectal cancer surgery; however, there is limited evidence regarding urogenital function comparing robotic to laparoscopic techniques. The aim of this study was to assess the urogenital functional outcomes of patients undergoing laparoscopic and robotic rectal cancer surgery. METHODS: Urological and sexual functions were assessed using gender-specific validated standardised questionnaires. Questionnaires were sent a minimum of 6 months after surgery, and patients were asked to report their urogenital function pre- and post-operatively, allowing changes in urogenital function to be identified. Questionnaires were sent to 158 patients (89 laparoscopy, 69 robotic) of whom 126 (80 %) responded. Seventy-eight (49 male, 29 female) of the responders underwent laparoscopic and 48 (35 male, 13 female) robotic surgery. RESULTS: Male patients in the robotic group deteriorated less across all components of sexual function and in five components of urological function. Composite male urological and sexual function score changes from baseline were better in the robotic cohort (p < 0.001). In females, there was no difference between the two groups in any of the components of urological or sexual function. However, composite female urological function score change from baseline was better in the robotic group (p = 0.003). CONCLUSION: Robotic rectal cancer surgery might offer better post-operative urological and sexual outcomes compared to laparoscopic surgery in male patients and better urological outcomes in females. Larger scale, prospective randomised control studies including urodynamic assessment of urogenital function are required to validate these results.
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Laparoscopia , Neoplasias Retais/fisiopatologia , Neoplasias Retais/cirurgia , Robótica , Sistema Urogenital/fisiopatologia , Idoso , Demografia , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Disfunções Sexuais Fisiológicas/etiologiaRESUMO
INTRODUCTION: The surgical treatment for locally advanced or recurrent rectal cancer requires oncological clearance with a pelvic exenteration or a beyond total mesorectal excision (TME). The aim of this systematic review is to explore the safety and feasibility of robotic surgery in locally advanced and recurrent rectal cancer by evaluating perioperative outcomes, oncological clearance rates, and survival and recurrence rates postrobotic beyond TME surgery. METHODS: The systematic review will include studies published until the end of December 2023. The MEDLINE, EMBASE and Scopus databases will be searched. The screening process, study selection, data extraction, quality assessment and analysis will be performed by two independent reviewers. Discrepancies will be resolved by consensus with a third independent reviewer. The risk of bias will be assessed with validated scores. The primary outcomes will be oncological clearance, overall and disease-free survival, and local and systemic recurrence rates post robotic or robot-assisted beyond TME surgery for locally advanced or recurrent rectal cancer. Secondary outcomes will include perioperative outcomes. ETHICS AND DISSEMINATION: No ethical approval is required for this systematic review as no individual patient cases are studied requiring access to individual medical records. The results of the systematic review will be disseminated with conference presentations and peer-reviewed paper publications. PROSPERO REGISTRATION OF THE STUDY: CRD42023408098.
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Laparoscopia , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Resultado do Tratamento , Laparoscopia/métodos , Revisões Sistemáticas como Assunto , Neoplasias Retais/cirurgiaRESUMO
BACKGROUND: The quality of care of patients receiving colorectal resections has conventionally relied on individual metrics. When discussing with patients what these outcomes mean, they often find them confusing or overwhelming. Textbook oncological outcome (TOO) is a composite measure that summarises all the 'desirable' or 'ideal' postoperative clinical and oncological outcomes from both a patient's and doctor's point of view. This study aims to evaluate the incidence of TOO in patients receiving robotic colorectal cancer surgery in five robotic colorectal units and understand the risk factors associated with failure to achieve a TOO in these patients. METHODS: We present a retrospective, multicentric study with data from a prospectively collected database. All consecutive patients receiving robotic colorectal cancer resections from five centres between 2013 and 2022 were included. Patient characteristics and short-term clinical and oncological data were collected. A TOO was achieved when all components were realized-no conversion to open, no complication with a Clavien-Dindo (CD) ≥ 3, length of hospital stay ≤ 14, no 30-day readmission, no 30-day mortality, and R0 resection. The main outcome measure was a composite measure of "ideal" practice called textbook oncological outcomes. RESULTS: A total of 501 patients submitted to robotic colorectal cancer resection were included. Of the 501 patients included, 388 (77.4%) achieved a TOO. Four patients were converted to open (0.8%); 55 (11%) had LOS > 14 days; 46 (9.2%) had a CD ≥ 3 complication; 30-day readmission rate was 6% (30); 30-day mortality was 0.2% (1); and 480 (95.8%) had an R0 resection. Abdominoperineal resection was a risk factor for not achieving a TOO. CONCLUSIONS: Robotic colorectal cancer surgery in robotic centres achieves a high TOO rate. Abdominoperineal resection is a risk factor for failure to achieve a TOO. This measure may be used in future audits and to inform patients clearly on success of treatment.
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Robotic rectal surgery is becoming increasingly more popular among colorectal surgeons. However, time spent on robotic platform docking, arm clashing and undocking of the platform during the procedure are factors that surgeons often find cumbersome and time consuming. The newest surgical platform, the da Vinci Xi, coupled with integrated table motion can help to overcome these problems. This technical note aims to describe a standardised operative technique of single docking robotic rectal surgery using the da Vinci Xi system and integrated table motion. A stepwise approach of the da Vinci docking process and surgical technique is described accompanied by an intra-operative video that demonstrates this technique. We also present data collected from a prospectively maintained database. 33 consecutive rectal cancer patients (24 male, 9 female) received robotic rectal surgery with the da Vinci Xi during the preparation of this technical note. 29 (88%) patients had anterior resections, and four (12%) had abdominoperineal excisions. There were no conversions, no anastomotic leaks and no mortality. Median operation time was 331 (249-372) min, blood loss 20 (20-45) mls and length of stay 6.5 (4-8) days. 30-day readmission rate and re-operation rates were 3% (n = 1). This standardised technique of single docking robotic rectal surgery with the da Vinci Xi is safe, feasible and reproducible. The technological advances of the new robotic system facilitate the totally robotic single docking approach.
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Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Retais/cirurgia , Reto/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Posicionamento do Paciente , Complicações Pós-Operatórias , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/mortalidade , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricosRESUMO
AIM: To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery. METHODS: A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: "rectal cancer" or "colorectal cancer" and robot* or "da Vinci" and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors. RESULTS: Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions. CONCLUSION: There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.