SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19.

BACKGROUND: SARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved. METHODS: Systematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed. RESULTS: In KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy. CONCLUSION: With demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume.

SAGES Reimagining Education & Learning (REAL) project.

BACKGROUND: The COVID-19 pandemic has presented multiple challenges for health systems throughout the world. The clinical priorities of redirecting personnel and resources to provide the necessary beds, care, and staff to handle the initial waves of infected individuals, and the drive to develop an effective vaccine, were the most visible and rightly took precedent. However, the spread of the COVID-19 virus also led to less apparent but equally challenging impediments for healthcare professionals. Continuing professional development (CPD) for physicians and surgeons practically ceased as national societies postponed or canceled annual meetings and activities. The traditional in-person conferences were no longer viable options during a pandemic in which social distancing and minimization of contacts was the emerging norm. Like other organizations, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) had to first postpone and then cancel altogether the in-person 2020 Annual Meeting due to the contingencies brought about by the COVID-19 pandemic. As a result, the traditional hands-on (HO) courses that typically occur as part of the Annual Meeting, could not take place. SAGES had already begun to re-structure these courses in an effort to increase their effectiveness (Dort, Trickey, Paige, Schwarz, Dunkin in Surg Endosc 33(9):3062-3068, 2019; Dort et al. in Surg Endosc 32(11):4491-4497, 2018; Dort, Trickey, Schwarz, Paige in Surg Endosc 33(9):3062-3068, 2019). The cancelations brought about by COVID-19 provided an opportunity to refine and to innovate further. METHODS: In this manner, the Re-imaging Education & Learning (REAL) project crystallized, an innovative effort to leverage the latest educational concepts as well as communication and simulation-based technologies to enhance procedural adoption by converting HO courses to a virtual format. RESULTS AND CONCLUSION: This manuscript describes the key components of REAL, reviewing the restructuring of the HO courses before and after the spread of COVID-19, describing the educational framework underlying it, discussing currently available technologies and materials, and evaluating the advantages of such a format.

Team training and surgical crisis management.

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

SAGES TAVAC safety and efficacy analysis confocal laser endomicroscopy.

BACKGROUND: Confocal laser endomicroscopy (CLE) is a novel endoscopic adjunct that allows real-time in vivo histological examination of mucosal surfaces. By using intravenous or topical fluorescent agents, CLE highlights certain mucosal elements that facilitate an optical biopsy in real time. CLE technology has been used in different organ systems including the gastrointestinal tract. There has been numerous studies evaluating this technology in gastrointestinal endoscopy, our aim was to evaluate the safety, value, and efficacy of this technology in the gastrointestinal tract. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Technology and Value Assessment Committee (TAVAC) performed a PubMed/Medline database search of clinical studies involving CLE in May of 2018. The literature search used combinations of the keywords: confocal laser endomicroscopy, pCLE, Cellvizio, in vivo microscopy, optical histology, advanced endoscopic imaging, and optical diagnosis. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. The manufacturer's website was also used to identify key references. The United States Food and Drug Administration (U.S. FDA) Manufacturer And User facility and Device Experience (MAUDE) database was searched for reports regarding the device malfunction or injuries. RESULTS: The technology offers an excellent safety profile with rare adverse events related to the use of fluorescent agents. It has been shown to increase the detection of dysplastic Barrett's esophagus, gastric intraepithelial neoplasia/early gastric cancer, and dysplasia associated with inflammatory bowel disease when compared to standard screening protocols. It also aids in the differentiation and classification of colorectal polyps, indeterminate biliary strictures, and pancreatic cystic lesions. CONCLUSIONS: CLE has an excellent safety profile. CLE can increase the diagnostic accuracy in a number of gastrointestinal pathologies.

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic.

The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.

SAGES TAVAC safety and efficacy analysis WATS3D (CDx Diagnostics, Suffern, NY).

BACKGROUND: Wide-area transepithelial sampling of the esophagus with computer-assisted three-dimensional analysis (WATS3D, CDx Diagnostics, Suffern, NY) is an adjunctive technique to random biopsies for early detection of Barrett's esophagus. The aim of the SAGES Technology and Value Assessment Committee aims is to evaluate the efficacy, value, and safety of WATS3D. METHODS: Clinical studies involving WATS3D were identified via a search of the PubMed/Medline databases ( www.ncbi.nlm.nih.gov/pubmed ) conducted in March of 2019 using search terms, such as wide-area transepithelial sampling, three-dimensional (3D) computer-assisted analysis, WATS-3D, Barrett's esophagus and WATS-3D, Barrett's esophagus and wide-area transepithelial sampling with three-dimensional computer-assisted analysis, Barrett's esophagus, and emerging technology. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. RESULTS: No significant morbidity or mortality was reported within the literature associated with the WATS3D technology. WATS3D increases diagnostic yield by 38-150% for Barrett's Esophagus, by 40-150% for Low Grade Dysplasia; and by 420% for High Grade Dysplasia; when compared to forceps biopsy alone. WATS3D technique has very high inter-observer agreement for the pathological diagnosis of non-dysplastic and dysplastic Barrett's Esophagus. Increased detection of pre-malignant diseases of the esophagus by the adjunctive use of WATS3D supports screening and surveillance by the adjunctive use of WATS3D during upper endoscopy in appropriate patients. CONCLUSION: Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D, CDx Diagnostics) is a safe and effective adjunct to forcep biopsies in the evaluation of Barrett's Esophagus, Low Grade Dysplasia, and High Grade Dysplasia.

Primary Fascial Closure During Laparoscopic Ventral Hernia Repair Improves Patient Quality of Life: A Multicenter, Blinded Randomized Controlled Trial.

BACKGROUND: Observational studies have reported conflicting results with primary fascial closure (PFC) versus bridged repair during laparoscopic ventral hernia repair (LVHR). OBJECTIVE: The aim of the study was to determine whether when evaluated in a randomized controlled trial (RCT), PFC compared to bridged repair would improve patient quality of life (QoL). METHODS: In this blinded, multicenter RCT, patients scheduled for elective LVHR (hernia defects 3 to 10 cm on computed tomography scan) were randomized to PFC versus bridged repair. Primary outcome was change in QoL after LVHR using a validated, hernia-specific survey (1 = poor QoL and 100 = perfect QoL) that measures pain, function, cosmesis, and satisfaction. Secondary outcomes were postoperative surgical site occurrences (including hematoma, seroma, surgical site infection, and wound dehiscence), abdominal eventration, and hernia recurrence. The trial was powered to detect a difference in change in QoL of 7 points between the study groups. Outcomes were compared with Mann-Whitney U test or chi-square. RESULTS: A total of 129 patients underwent LVHR and 107 (83%) completed follow-up at 2 years. Patients from both groups were similar at baseline. On median follow-up of 24 months (range: 9-42), patients treated with LVHR-PFC had on average a 12-point higher improvement in QoL compared to bridged repair (improvement in QoL, 41.3 ± 31.5 vs 29.7 ±â€Š28.7, P value = 0.047). There were no differences in surgical site occurrence, eventration, or hernia recurrence between groups. CONCLUSIONS: Among patients undergoing elective LVHR, the fascial defect should be closed. This is the first RCT demonstrating that PFC with LVHR significantly improves patient QoL. TRIAL REGISTRATION: This trial was registered with clinicaltrials.gov (NCT02363790).

Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study.

OBJECTIVE: To report 1-year results from a 5-year mandated study. SUMMARY BACKGROUND DATA: In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD). Continued assessment of safety and effectiveness has been monitored in a Post Approval Study. METHODS: Multicenter, prospective study of patients with pathologic acid reflux confirmed by esophageal pH testing undergoing MSA. Predefined clinical outcomes were assessed at the annual visit including a validated, disease-specific questionnaire, esophagogastricduodenoscopy and esophageal pH monitoring, and use of proton pump inhibitors. RESULTS: A total of 200 patients (102 males, 98 females) with a mean age of 48.5 years (range 19.7-71.6) were treated with MSA between March 2013 and August 2015. At 1 year, the mean total acid exposure time decreased from 10.0% at baseline to 3.6%, and 74.4% of patients had normal esophageal acid exposure time (% time pH<4 ≤5.3%). GERD Health-Related Quality of Life scores improved from a median score of 26.0 at baseline to 4.0 at 1 year, with 84% of patients meeting the predefined success criteria of at least a 50% reduction in total GERD Health-Related Quality of Life score compared with baseline. The device removal rate at 1 year was 2.5%. One erosion and no serious adverse events were reported. CONCLUSIONS: Safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm MSA as treatment for GERD.

Abdominal Wall Reconstruction Risk Stratification Tools: A Systematic Review of the Literature.

BACKGROUND: Ventral hernias are a common pathology encountered by surgeons. Multiple risk stratification tools have been developed in attempts to predict a patient's postoperative risk for complication. The aim of this systematic review was to identify published stratification tools, to assess their generalizability, and develop an ensemble risk score model. METHODS: A systematic review of the literature was performed using PubMed and following the PRISMA guidelines. Two independent reviewers identified articles describing hernia stratification tools or validating an established tool. Inclusion criteria included articles that studied ventral hernia risk score models developed through expert consensus or from data of at least 500 subjects, performed a multivariable analysis of at least 500 patients, or assessed a previously reported model. Studies were grouped by primary outcome, and the odds ratios for correlated variables were compiled. Outcomes described in 4 or more articles were then stacked to generate a cumulative risk score model for patients undergoing abdominal wall repair. RESULTS: A total of 20 articles were found to meet our inclusion criteria and used to develop our ensemble model. Surgical-site infection, surgical-site occurrence, and hernia recurrence were the 3 primary outcomes used to calculate our stacked cumulative risk stratification score. CONCLUSIONS: There are multiple risk score tools published; however, all have their strengths and limitations. For this reason, we created a composite score model with data from major articles to predict a patient's risk for postoperative complications. This model aims to ease the shared-decision making process for patients, surgeons, and institutions.

Multicenter review of robotic versus laparoscopic ventral hernia repair: is there a role for robotics?

BACKGROUND: The utilization of robotic platforms for general surgery procedures such as hernia repair is growing rapidly in the United States. A limited amount of data are available evaluating operative outcomes in comparison to standard laparoscopic surgery. We completed a retrospective review comparing robotic and laparoscopic ventral hernia repair to provide safety and outcomes data to help design a future prospective trial design. METHODS: A retrospective review of 215 patients undergoing ventral hernia repair (142 robotic and 73 laparoscopic) was completed at two large academic centers. Primary outcome measure evaluated was recurrence. Secondary outcomes included incidence of primary fascial closure, and surgical site occurrences. RESULTS: Propensity for treatment match comparison demonstrated that robotic repair was associated with a decreased incidence of recurrence (2.1 versus 4.2%, p < 0.001) and surgical site occurrence (4.2 versus 18.8%, p < 0.001). This may be because robotic repair was associated with increased incidence of primary fascial closure (77.1 versus 66.7%, p < 0.01). Analysis of baseline patient populations showed that robotic repairs were completed on patients with lower body mass index (28.1 ± 3.6 versus 34.2 ± 6.4, p < 0.001) and fewer comorbidities. CONCLUSIONS: Our retrospective data show that robotic repair was associated with decreased recurrence and surgical site occurrence. However, the differences noted in the patient populations limit the interpretability of these results. As adoption of robotic ventral hernia repair increases, prospective trials need to be designed in order to investigate the efficacy, safety, and cost effectiveness of this evolving technique.

Distraction and proficiency in laparoscopy: 2D versus robotic console 3D immersion.

INTRODUCTION: Studies have shown that using robotic-assisted laparoscopy (RL) increases performance compared to conventional laparoscopy (CL) due to its mechanical advantages but have not assessed distraction as a factor. To determine whether the immersive aspect of the 3D optics in RL contributes to improved performance, we compared the outcomes of laparoscopic skills by using just the 3D optics of the da Vinci versus the conventional 2D monitor with and without distraction. METHODS: Thirty-two participants without any laparoscopic experience were randomized evenly into four groups: RL, robotic-assisted laparoscopy with distraction (RL + D), CL, and conventional laparoscopy with distraction (CL + D). Each participant performed three Fundamentals of Laparoscopy Surgery tasks [peg transfer (Task 1), circle cutting (Task 2), and suturing with knot (Task 3)] for three repetitions. For each task, the mean time and errors were recorded and analyzed statistically for each group. RESULTS: Compared to other groups, CL + D took on average 1 min longer to complete Task 1 (P = 0.001), more than 1 min to complete Task 2 (P = 0.003), and more than 2 min to complete the Task 3 (P < 0.001). On Task 2, the deviations from the pattern were shorter for RL and RL + D compared to CL and CL + D (mean 0.33 and 0.37 cm vs. 0.55 and 0.58 cm, respectively; P < 0.001). On Task 3, the deviations were also shorter for RL and RL + D compared to CL and CL + D (mean 0.23 and 0.24 mm vs. 0.61 and 0.63 mm, respectively; P < 0.001). CONCLUSION: When distraction was introduced, CL performed significantly worse. This suggests that using the conventional 2D monitor does not help with blocking out distraction. For Tasks 2 and 3, which require more precision and depth perception, the groups that used the 3D optics had shorter mean deviations than groups that used the conventional 2D monitor. This suggests that even when the robotic arms of the da Vinci are removed, there are still advantages to the immersive 3D optics, especially when distraction is present. The immersive aspect of the 3D optics may help improve performance in the OR, allowing surgeons to be more focused on the case and have greater depth acuity.

Troubleshooting common endoscopic malfunctions: a study integrating a preoperative checklist and troubleshooting guide into surgical resident training.

INTRODUCTION: This study assessed the utility of a checklist in troubleshooting endoscopic equipment. Prior studies have demonstrated that performance in simulated tasks translates into completion of similar tasks in the operating room. Checklists have been shown to decrease error and improve patient safety. There is currently limited experience with the use of simulation and checklists to improve troubleshooting of endoscopic equipment. We propose the use of a checklist during a simulated colonoscopy to improve performance during endoscopic troubleshooting. METHODS: This study randomized 20 surgical residents (PGY1-3) who were blinded to the purpose of the simulation. Participants were asked to complete two consecutive colonoscopies in a mock endoscopy suite. Prior to each trial, a standard set of equipment malfunctions were created; the equipment was returned to working order if the subjects were unable to successfully troubleshoot the equipment within the first 3 min of the simulation. Between trials, the intervention group was provided a troubleshooting checklist, which they were permitted to utilize during the second trial. The control group had no intervention. Scores were calculated for each task by subtracting time to completion from total time allowed (180 s), with 0 indicating the task was not completed. Groups were compared utilizing unpaired Student's t-test with p < 0.05 threshold for significance. RESULTS: Average scores were compared for 5 tasks in the first trial and 6 tasks in the second trial. During the first trial, there were no significant differences. However, during the second trial, there was a significant improvement with the checklist for 5/6 tasks. CONCLUSION: Use of a checklist, with no further intervention, significantly improves the ability of novice endoscopists to identify and remedy common equipment malfunctions. Introduction of a troubleshooting checklist may represent a simple and low-cost way to improve both efficiency and safety in the endoscopy suite.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

OBJECTIVE: To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Incidence of Port-Site Hernias: A Survey and Literature Review.

BACKGROUND: The impact of laparoscopy on the prevalence of incisional hernias remains unclear. The aim of this study is to determine (1) surgeon perceptions of port-site hernias (PSHs), (2) the true incidence of PSH. MATERIALS AND METHODS: A survey on PSH was given to determine the surgeon-reported rate of PSH. A literature review was performed for studies with a primary outcome of PSH. Studies were evaluated using checklists, and scores were used to compare risk of bias. Risk of bias was graphed against PSH incidence. RESULTS: From 38 surgeons surveyed, the surgeon perceived rate of PSH was a median (range) of 0.5% (0% to 5%) for ports ≤5 mm, 5% (0.1% to 20%) for ports extended, and 5% (0.1% to 40%) for ports ≥10 mm. Thirty studies showed a PSH rate from 0% to 39.3%. Higher quality studies reported higher rates of PSH. CONCLUSIONS: Surgeons underestimate the incidence of PSH, but high-quality literature suggests that it may be nearly 40%.

Putting the MeaT into TeaM Training: Development, Delivery, and Evaluation of a Surgical Team-Training Workshop.

BACKGROUND: Despite importance to patient care, team training is infrequently used in surgical education. To address this, a workshop was developed by the Association for Surgical Education Simulation Committee to teach team training using high-fidelity patient simulators and the American College of Surgeons-Association of Program Directors in Surgery team-training curriculum. METHODS: Workshops were conducted at 3 national meetings. Participants completed preworkshop and postworkshop questionnaires to define experience, confidence in using simulation, intention to implement, as well as workshop content quality. The course consisted of (A) a didactic review of Preparation, Implementation, and Debriefing and (B) facilitated small group simulation sessions followed by debriefings. RESULTS: Of 78 participants, 51 completed the workshops. Overall, 65% indicated that residents at their institutions used patient simulation, but only 33% used the American College of Surgeons-the Association of Program Directors in Surgery team-training modules. The workshop increased confidence to implement simulation team training (3.4 ± 1.3 vs 4.5 ± 0.9). Quality and importance were rated highly (5.4 ± 00.6, highest score = 6). CONCLUSIONS: Preparation for simulation-based team training is possible in this workshop setting, although the effect on actual implementation remains to be determined.

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains.

BACKGROUND: Key research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved. METHODS: Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel. RESULTS: Excellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive. CONCLUSIONS: Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA).

BACKGROUND: The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted. METHODS: The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval. RESULTS: Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy. CONCLUSIONS: Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Financing a Simulation Center.

As simulation-based training has become established within medical and health professional disciplines, skills training laboratories have become a standard in surgery training programs. In 2008, the American College of Surgeons and Association of Program Directors in Surgery developed a simulation-based surgical skills curriculum; the Residency Review Committee for Surgery of the Accreditation Council for Graduate Medical Education mandated access to skills laboratories for all surgery programs. Establishing a surgical skills laboratory and adapting the training curriculum requires a significant amount of resources. This article discusses the financial aspects of establishing a training center, from funding opportunities to budgeting considerations.

Intraoperative use of fluorescent imaging with indocyanine green changes management of abdominal wall flaps during open ventral hernia repair.

BACKGROUND: Wound complications including infection and necrosis remain common during complex open ventral hernia repair. Advancements or enhancements in imaging technology may abate some of these issues but requires more investigation. Laser-assisted fluorescent imaging with indocyanine green (Spy Elite, LifeCell Corporation, Branchburg, NJ) allows visualization and quantification of perfusion, facilitating management of poorly perfused tissue. METHODS: Ten patients, who underwent large or massive ventral or incisional hernia repair with biologic graft reinforcement and either perforator-sparing components separation or primary open repair, underwent intraoperative laser-assisted fluorescent imaging with indocyanine green from August 2012 to August 2013. The cases were reviewed by an independent data collector with primary outcomes of postoperative skin infection and/or abdominal wall necrosis. RESULTS: Three (30%) patients had adequate perfusion, while seven (70%) patients had inadequate skin perfusion and necessitated excision of additional tissue. Of the patients whose ischemic tissue was removed, four (57%) patients had an infection and no patients developed necrosis postoperatively. Of the patients who had no removal of additional skin, one (33%) patient developed an infection and one (33%) patients developed skin necrosis. CONCLUSION: The intraoperative use of laser-assisted fluorescent imaging with indocyanine green may change management of abdominal wall flaps, even in perforator-sparing operations. Our study series is small and cannot suggest statistical significance in the potential benefit of intraoperative imaging, but shows that up to 70% of patients may require change in management due to poorly perfused tissue flaps.

Retention of fundamentals of laparoscopic surgery (FLS) proficiency with a biannual mandatory training session.

BACKGROUND: The fundamentals of laparoscopic surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in 1997 with the goal of teaching surgeons the fundamental knowledge, judgment, and technical skills specific to laparoscopic surgery (Peters et al., Surgery JH 135:21-27, 2004; Soper et al., Bull Am College Surg NJ 93:30-32, 2008). This single academic institution observational study aimed to assess the effectiveness of a biannual FLS training curriculum on Post-Graduate Year [PGY] 1-5 proficiency levels, with a focus on one FLS task (PEG transfer). Previous studies have shown that obtaining expert FLS proficiency correlates with retaining proficiency in the future (Castellvi et al., Surgery 146:387-393, 2009). METHODS: PGY 1-5 residents (n = 28) at an academic general surgery residency program performed two timed PEG transfer tasks biannually. Participants were monitored by FLS certified examiners and standard FLS rules applied. Residents were expected to meet or exceed standards set by SAGES and FLS in consecutive timed PEG transfer trials (proficiency: <48 s). RESULTS: Twenty-eight residents participated (PGY 1-5). Participants showed proficiency if they completed the PEG transfer task in less than 48 s on two consecutive trials. None of the PGY 1 or PGY 2 residents completed two consecutive trials within the stated proficiency time, while the majority of the PGY 3-5 residents showed proficiency in the PEG transfer task. CONCLUSION: A biannual training session for FLS retains expert proficiency by PGY levels 4-5. Previous reports from our institution demonstrated that 95 % of the residents did not practice this task between mandatory biannual sessions. This suggests that, in combination with standard residency training, biannual FLS sessions confer retained expert skills by PGY 4-5. As the FLS exam is generally taken by PGY 4 and 5 residents and is required for board certification, general surgery residents that participate in biannual training sessions will likely retain expert proficiency and achieve FLS certification.