Development and validity evidence of an objective structured assessment of technical skills score for minimally invasive linear-stapled, hand-sewn intestinal anastomoses: the A-OSATS score.

INTRODUCTION: The aim of this study was to develop a reliable objective structured assessment of technical skills (OSATS) score for linear-stapled, hand-sewn closure of enterotomy intestinal anastomoses (A-OSATS). MATERIALS AND METHODS: The Delphi methodology was used to create a traditional and weighted A-OSATS score highlighting the more important steps for patient outcomes according to an international expert consensus. Minimally invasive novices, intermediates, and experts were asked to perform a minimally invasive linear-stapled intestinal anastomosis with hand-sewn closure of the enterotomy in a live animal model either laparoscopically or robot-assisted. Video recordings were scored by two blinded raters assessing intrarater and interrater reliability and discriminative abilities between novices (n = 8), intermediates (n = 24), and experts (n = 8). RESULTS: The Delphi process included 18 international experts and was successfully completed after 4 rounds. A total of 4 relevant main steps as well as 15 substeps were identified and a definition of each substep was provided. A maximum of 75 points could be reached in the unweighted A-OSATS score and 170 points in the weighted A-OSATS score respectively. A total of 41 anastomoses were evaluated. Excellent intrarater (r = 0.807-0.988, p < 0.001) and interrater (intraclass correlation coefficient = 0.923-0.924, p < 0.001) reliability was demonstrated. Both versions of the A-OSATS correlated well with the general OSATS and discriminated between novices, intermediates, and experts defined by their OSATS global rating scale. CONCLUSION: With the weighted and unweighted A-OSATS score, we propose a new reliable standard to assess the creation of minimally invasive linear-stapled, hand-sewn anastomoses based on an international expert consensus. Validity evidence in live animal models is provided in this study. Future research should focus on assessing whether the weighted A-OSATS exceeds the predictive capabilities of patient outcomes of the unweighted A-OSATS and provide further validity evidence on using the score on different anastomotic techniques in humans.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer.

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

Virtual reality does not meet expectations in a pilot study on multimodal laparoscopic surgery training.

BACKGROUND: The purpose of the present study was to determine the value of virtual reality (VR) training for a multimodality training program of basic laparoscopic surgery. MATERIALS AND METHODS: Participants in a two-day multimodality training for laparoscopic surgery used box trainers, live animal training, and cadaveric training on the pulsating organ perfusion (POP) trainer in a structured and standardized training program. The participants were divided into two groups. The VR group (n = 13) also practiced with VR training during the program, whereas the control group (n = 14) did not use VR training. The training modalities were assessed using questionnaires with a five-point Likert scale after the program. Concerning VR training, members of the control group assessed their expectations, whereas the VR group assessed the actual experience of using it. Skills performance was evaluated with five standardized test tasks in a live porcine model before (pre-test) and after (post-test) the training program. Laparoscopic skills were measured by task completion time and a general performance score for each task. Baseline tests were compared with laparoscopic experience of all participants for construct validity of the skills test. RESULTS: The expected benefit from VR training of the control group was higher than the experienced benefit of the VR group. Box and POP training received better ratings from the VR group than from the control group for some purposes. Both groups improved their skill parameters significantly from pre-training to post-training tests [score +17 % (P < 0.01), time -29 % (P < 0.01)]. No significant difference was found between the two groups for laparoscopic skills improvement except for the score in the instrument coordination task. Construct validity of the skills test was significant for both time and score. CONCLUSIONS: At its current level of performance, VR training does not meet expectations. No additional benefit was observed from VR training in our multimodality training program.

Feasibility of a high intrathoracic esophagogastric anastomosis without thoracic access after laparoscopic-assisted transhiatal esophagectomy: a pilot experimental study.

INTRODUCTION: The aim of the present study was to evaluate the feasibility of a technique that uses solely the transhiatal approach to create a high intrathoracic esophagogastric anastomosis after laparoscopic transhiatal resection of the distal esophagus. METHOD: Using a laparoscopic approach, the esophagi of 10 midsized pigs were dissected and transected as high as possible in the thorax, and the anvil of a circular stapler was introduced perorally into the esophageal stump. Through a midline short laparotomy, the circular stapler was inserted into the gastric tube and advanced through the hiatus to be connected with the anvil and create the anastomosis. RESULTS: Development of the technique was completed within the first 6 experiments. The last 4 operations were entirely successful, standardized, and easily reproducible. CONCLUSION: The technique is feasible in this experimental setting. Further studies are required to establish if there is a clinical role for this technique in esophageal surgery.

Robotic-assisted transhiatal esophagectomy.

BACKGROUND: Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis. MATERIALS AND METHODS: The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy. RESULTS: Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome. CONCLUSION: The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.