Influence of previous experience on the benefits of laparoscopic surgical training based on simulation. / Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación.

INTRODUCTION: Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing sill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyse their results depending on their level and previous experience. METHODS: The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analysed. Manual side-to-side intestinal anastomoses with porcine 'ex vivo' viscera were performed in a laparoscopic endotrainer. The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared. RESULTS: We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (p<.001). In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, p=.59), which presented improvement without statistical significance. CONCLUSIONS: The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course.

Robotic Assisted Transanal Polypectomies: Is There Any Indication? / Polipectomía transanal asistida por robot: ¿tiene alguna indicación?

OBJECTIVES: Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique. METHODS: Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality. RESULTS: A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm2. All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days. CONCLUSIONS: Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions.

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos / Effects of surgical simulation on the implementation of laparoscopic colorectal procedures

INTRODUCCIÓN: La cirugía laparoscópica avanzada necesita complementar el aprendizaje fuera del quirófano. La simulación clínica con animales o cadáveres favorece este aprendizaje. OBJETIVO: Mostrar el grado de impacto en la práctica quirúrgica diaria en los cirujanos que realizaron un curso clínico-experimental de cirugía colorrectal laparoscópica. MATERIAL Y MÉTODO: Entre marzo de 2007 y marzo de 2012, realizamos 30 cursos de 4 días de duración, durante 35 h (18 en quirófano, 12 en animales de experimentación y 4 en seminarios), en los que participaron 163 cirujanos. En mayo de 2012, vía online, se les remitió una encuesta con la finalidad de evaluar el impacto que este curso podía haber tenido en su práctica diaria de cirugía colorrectal laparoscópica. RESULTADOS: El número de encuestas contestadas fue de 70 (47%), que correspondían a cirujanos de 60 hospitales diferentes. El periodo medio tras el curso fue de 11,5 meses (2-60). El 75% de los cirujanos iniciaron o aumentaron el número de cirugías que realizan después del curso, siendo este aumento menor de 5 casos/mes en el 56% y mayor de 10 casos/mes en el 19%. El 38% iniciaron esta vía de abordaje. CONCLUSIONES: El 75% de los cirujanos encuestados aumentaron la implementación clínica de una técnica quirúrgica compleja como es la cirugía colorrectal por vía laparoscópica, después de realizar un curso de entrenamiento apoyado en simulación clínica

INTRODUCTION: Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning. OBJECTIVE: We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation. MATERIAL AND METHODS: Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12 h in animal models, and 4 h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work. RESULTS: Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was > 10 cases/month in 19%, and < 5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach. CONCLUSIONS: Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation

[Effects of surgical simulation on the implementation of laparoscopic colorectal procedures]. / Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos.

INTRODUCTION: Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning. OBJECTIVE: We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation. MATERIAL AND METHODS: Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12h in animal models, and 4h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work. RESULTS: Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was>10 cases/month in 19%, and<5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach. CONCLUSIONS: Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.

Evaluación del entrenamiento de residentes en cirugía laparoscópica en el laboratorio basado en un modelo de anastomosis digestivas / Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory

IntroducciónLa complejidad de la cirugía laparoscópica hace necesario un entrenamiento específico fuera del quirófano para acortar la curva de aprendizaje y reducir la morbilidad. El objetivo del estudio es analizar la progresión en habilidades laparoscópicas tras un programa de entrenamiento en laboratorio.Material y métodosEstudio prospectivo de un programa de entrenamiento de residentes de 4 semanas anuales (20 h semanales) basado en anastomosis en endotrainer, realizado entre 2004 y 2007. Los parámetros principales fueron tiempo y número de anastomosis necesarias hasta llegar a una correcta ejecución. Una vez completada, la anastomosis se revisó conjuntamente mediante un residente y un monitor. Se registraron tiempo de ejecución y fallos anastomóticos (sutura floja, eversión de bordes y fuga).ResultadosDoce residentes realizaron 189 anastomosis yeyunoyeyunales (AYY) (media: 15,8) y 197 anastomosis gastroyeyunales (AGY) (media: 16,4). El tiempo medio de las AYY fue de 72,7min y el de las AGY fue de 87,2min. Se observó una gran reducción en el tiempo de ejecución desde el comienzo al final del programa. El porcentaje de anastomosis incorrectas disminuyó en función del tiempo de entrenamiento: el 26,6; el 21,8; el 17,1; el 17; el 16,1 y el 10,5% después de 20; 40; 60; 80; 100 y 120h, respectivamente. Considerando la reducción, tanto en tiempo de ejecución como en el índice de anastomosis incorrectas, después de 70h de entrenamiento la curva de aprendizaje alcanzaba una meseta.ConclusionesEl entrenamiento en endotrainer basado en anastomosis intestinales (tanto AYY o AGY) constituye un método útil de entrenamiento laparoscópico. Después de un entrenamiento de 70h se aprecia poca progresión (AU)

BackgroundThe complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program.Material and methodsProspective study of surgical resident training based on anastomosis performance on an “endotrainer”. The program consisted of 4 weeks per year (20h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded.ResultsTwelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1% and 10.5% after 20, 40, 60, 80, 100 and 120h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70h of training the learning curve reaches a plateau zone.ConclusionsIntestinal anastomosis (either JJA or GJA) performed in “endotrainer” is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit (AU)

[Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory]. / Evaluación del entrenamiento de residentes en cirugía laparoscópica en el laboratorio basado en un modelo de anastomosis digestivas.

BACKGROUND: The complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program. MATERIAL AND METHODS: Prospective study of surgical resident training based on anastomosis performance on an "endotrainer". The program consisted of 4 weeks per year (20h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded. RESULTS: Twelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7 min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1% and 10.5% after 20, 40, 60, 80, 100 and 120 h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70 h of training the learning curve reaches a plateau zone. CONCLUSIONS: Intestinal anastomosis (either JJA or GJA) performed in "endotrainer" is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit.