Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions.

OBJECTIVE: Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI). METHODS: A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a five point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on 10 previously videorecorded elective PVI cases. RESULTS: The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (interquartile range [IQR] 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case. CONCLUSION: An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.

Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation.

BACKGROUND: Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale. STUDY DESIGN: In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated. RESULTS: Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out. CONCLUSIONS: Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

Creating a Practical Transformational Change Management Model for Novel Artificial Intelligence-Enabled Technology Implementation in the Operating Room.

Objective: To identify change management (CM) strategies for implementing novel artificial intelligence and similar novel technologies in operating rooms and create a new CM model for future trials and applications inspired by the abovementioned strategies and established models. Methods: Key phases of technology implementation were defined, and strategies for transformational CM were created and applied in a recent CM experience at our institution between October 15, 2020 and October 15, 2021. We appraised existing CM models and propose the newly created model. Results: The key phases of the technology implementation were as follows: (1) team assembly; (2) committee approvals; (3) CM; and (4) system installation and go-live. Key strategies were (1) assemble team with necessary expertise; (2) anticipate potential institutional cultural and regulatory hurdles; (3) add agility to project planning and execution; (4) accommodate institutional culture and regulations; (5) early clinical partner buy-in and stakeholder engagement; and (6) consistent communication, all of which contributed to the new CM model creation. Conclusion: Key CM strategies and a new CM model addressing the unique needs and characteristics of operating room novel technology implementation were identified and created. The new model may be customized and tested for individual institution and project's needs and characteristics.

The Operating Room Black Box: Understanding Adherence to Surgical Checklists.

OBJECTIVE: We report for the first time the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. BACKGROUND: Implementation of operative checklists is associated with improved outcomes. Compliance is difficult to monitor. Most studies report either no assessment of checklist compliance or deployed in-person short-term assessment. The ORBB a novel artificially intelligence-driven data analytic platform affords the opportunity to assess checklist compliance without disrupting surgical workflow. METHODS: This was a retrospective review of prospectively collected ORBB data. Operative cases included elective surgery at a quaternary referral center. Cases were analyzed as prepolicy change (first 9 months) or as a postpolicy change (last 9 months). Measures of checklist compliance, engagement, and quality were assessed. RESULTS: There were 3879 cases that were performed and monitored for checklist compliance between August 15, 2020, and February 20, 2022. The overall scores for compliance, engagement, and quality were 81%, 84%, and 67% respectively. When broken down by phase, the scores for time-out were compliance 100%, engagement 98%, and quality 61%. Scores for the debrief phase were 81% for compliance, 98% for engagement, and 66% for quality. After a hospital policy change, the debrief scores improved significantly (85%; P <0.001 for compliance, 88%; P <0.001 for engagement and 71%; P <0.001 for quality). CONCLUSIONS: ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. Utilization of this technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

BACKGROUND: Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships. METHODS: A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects. RESULTS: 300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC's influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators. CONCLUSION: There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

Step, Error, and Event Frameworks in Endovascular Aortic Repair.

OBJECTIVE: Competency-based surgical education requires detailed and actionable feedback to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (ORBB; Surgical Safety Technologies, Inc), which continuously records and synchronizes multiple sources of intraoperative data, have recently been integrated into hybrid rooms to provide targeted feedback to endovascular teams. The objective of this study is to develop step, error, and event frameworks to evaluate technical performance in elective endovascular aortic repair (EVAR) comprehensively captured by the ORBB (Surgical Safety Technologies, Inc; Toronto, Canada). METHODS: This study is based upon a modified Delphi consensus process to create evaluation frameworks for steps, errors, and events in EVAR. International experts from Vascular Surgery and Interventional Radiology were identified, based on their records of publications and invited presentations, or serving on relevant journal editorial boards. In an initial open-ended survey round, experts were asked to volunteer a comprehensive list of steps, errors, and events for a standard EVAR of an infrarenal aorto-iliac aneurysm (AAA). In subsequent survey rounds, the identified items were presented to the expert panel to rate on a 5-point Likert scale. Delphi survey rounds were repeated until the process reached consensus with a predefined agreement threshold (Cronbach α>0.7). The final frameworks were constructed with items achieving an agreement (responses of 4 or 5) from greater than 70% of experts. RESULTS: Of 98 invited proceduralists, 38 formed the expert consensus panel (39%), consisting of 29 vascular surgeons and 9 interventional radiologists, with 34% from North America and 66% from Europe. Consensus criteria were met following the third round of the Delphi consensus process (Cronbach α=0.82-0.93). There were 15, 32, and 25 items in the error, step, and event frameworks, respectively (within-item agreement=74%-100%). CONCLUSION: A detailed evaluation tool for the procedural steps, errors, and events in infrarenal EVAR was developed. This tool will be validated on recorded procedures in future work: It may focus skill development on common errors and hazardous steps. This tool might be used to provide high-quality feedback on technical performance of trainees and experienced surgeons alike, thus promoting surgical mastery.

Evaluating quality and completeness of gastrectomy for gastric cancer: review of surgical videos from the public domain.

BACKGROUND: YouTube® has provided a forum to share surgical videos in the public domain which may be used for education. The quality of surgery and accompanying educational material is unknown. YouTube® videos of gastrectomy with D2 lymphadenectomy (D2-LND) for gastric cancer were evaluated for quality and completeness. METHODS: YouTube® was searched using the terms "D2 lymphadenectomy" and "Gastric Cancer" for open and laparoscopic videos. The Korean Laparoscopic Gastrointestinal Surgical Society (KLASS) outlined 22 steps that define quality and completeness of D2-LND. These guidelines were used to score D2-LND for each video. Four physician reviewers independently scored each surgical video. Scores were compared using Student's t-test. RESULTS: Ten laparoscopic and 10 open surgery videos were assessed. Each video was scored for quality and completeness and assigned a score out of 22. Mean score for open D2-LND was 15 (95% CI: 12.54-17.46). Mean score for laparoscopic D2-LND was 15.4 (95% CI: 14.34-16.46; P=0.77). The most consistently performed steps were the dissection of lymph node stations 1, 3, 4 and 5. The most commonly omitted steps were the dissection of lymph node station 6: exposure and identification of the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein. CONCLUSIONS: There is a wide range of quality and completeness of D2-LND videos. On average, D2-LND videos are only two-thirds complete.

Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study.

Introduction Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes that jeopardize safety and efficiency. In this study, our objective was to identify and characterize procedural steps, intraoperative distractions, errors, and threats, as well as the non-technical skills of the team during a common minimally invasive gynecologic procedure. Methodology This was a cross-sectional pilot study of 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device (ORBB). Trained analysts reviewed and coded the recordings. Results The median total case time was 165 minutes (interquartile range [IQR]: 160-178 minutes) with the shortest step being cystoscopy and the longest being vaginal cuff closure. Time pressure and device absence or malfunction occurred in 48% of the cases, and a median of 262 (IQR: 228-304) auditory distractions were noted per case. There was a median of 3 (IQR: 2-4) safety threats identified per case and at least one error was identified in 11/25 cases (44%). Only two adverse events were noted among all 25 cases. Observed non-technical skills were mainly positive, and observations were the highest for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. Conclusions This study is a novel application of the ORBB in the gynecology operating room to capture information regarding procedure times, intraoperative distractions, errors, and non-technical skills of the team. Frequent intraoperative cognitive and auditory distractions were noted. Although adverse events were rare, safety threats were identified. Ongoing and future research from our group will aim to identify key areas for organizational, technological, and team improvement to minimize inefficiencies and optimize patient safety in the operating room.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury.

BACKGROUND: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. STUDY DESIGN: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. RESULTS: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. CONCLUSIONS: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Assessing the effect of a hands-on oncoplastic surgery training course: A survey of Canadian surgeons.

BACKGROUND: The adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons' comfort with oncoplastic techniques and rate of adoption of these techniques in their practice. MATERIAL AND METHODS: An online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages. RESULTS: A total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning. CONCLUSION: A hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.

Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Background: Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME. Methods: Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME. Results: Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1­80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15­25 cases] v. 15 cases [IQR 10­20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10­19 cases] v. 9 cases [IQR 5­10 cases]). Conclusion: These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME.

Contexte: Selon des données préliminaires, l'exérèse totale du mésorectum par voie transanale (ou TaTME, pour transanal total mesorectal excision) est une solution de rechange sécuritaire à l'approche abdominale pour le cancer du rectum. Cette étude vise à faire le point sur le traitement du cancer rectal au Canada et à mesurer l'intérêt à l'endroit de la technique TaTME. Méthodes: Des chirurgiens ont été invités à répondre à un sondage sur leur façon de prendre en charge le cancer rectal et sur leur opinion au sujet de la TaTME. Résultats: Quatre-vingt-quatorze chirurgiens ont répondu au sondage (taux deréponse 38 %). Le nombre de cancer rectaux traités annuellement par chirurgien variait grandement (de 1 à 80 cas, nombre médian 15 cas). Vingt-sept pour cent des participants appliquaient la TaTME au moment du sondage et 43 % de ceux qui ne l'appliquaient pas disait avoir l'intention de s'y initier. Les chirurgiens qui appliquaient la TaTME se disaient d'avis qu'il fallait un volume annuel plus élevé de cas de cancer rectal pour garder la main comparativement aux chirurgiens qui n'appliquaient pas cette technique (nombre médian de 20 cas [éventail interquartile (ÉIQ) 15­25 cas] c. 15 cas [ÉIQ 10­20 cas]). Les chirurgiens qui appliquaient la TaTME ont aussi estimé qu'il fallait un volume annuel plus élevé de cas de TaTME pour garder la main (nombre médian de 12 cas [ÉIQ 10­19 cas] c. 9 cases (ÉIQ 5­10 cas]). Conclusion: Ces observations permettent de mieux définir les pratiques actuelles des chirurgiens qui soignent le cancer rectal au Canada et mettent en lumière les enjeux complexes inhérents à l'apprentissage de la TaTME.

Learning by Example: An International Perspective on Reflex-Testing for Lynch Syndrome.

BACKGROUND: Lynch syndrome (LS), an autosomal dominant cancer syndrome, is the most common cause of hereditary colon cancer. Currently, however, less than 5% of patients with LS have been identified. Reflex-testing programs (in which tumors of patients with colorectal cancer are routinely evaluated for LS) have been proposed for better identification of affected individuals, yet the uptake of these programs within health care systems is limited. This study explored the structure, implementation challenges, and future directions of existing international population-based reflex LS testing programs. METHODS: The study identified existing reflex-testing LS programs through the current literature and through a qualitative sampling approach. Key informants from each program were interviewed. Qualitative data were analyzed using a grounded theory analytic technique approach. RESULTS: The interviews were completed by 26 informants across seven identified programs. Three key themes were identified: (1) tension between a program imposed on stakeholders (a top-down approach) versus initiation of the program at the stakeholder level (bottom-up approach), (2) identification of pathologists as drivers of program success, and (3) strategies to optimize possible LS patients liaising with genetic counselors. Barriers to successful implementation included lack of stakeholder engagement and concerns regarding cost. Facilitators included strong administration to coordinate patient tracking and flexibility during the implementation process. CONCLUSIONS: Existing reflex-testing LS programs have varying structures, standards, and protocols. Program design can have a direct effect on the uptake of genetic testing. These are important considerations in the large-scale planning of LS reflex-testing programs within health systems.

A framework to build capacity for a reflex-testing program for Lynch syndrome.

PURPOSE: Lynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada. METHODS: We recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed. RESULTS: Twenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified. CONCLUSIONS: This study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.

Peer coaching to teach faculty surgeons an advanced laparoscopic skill: A randomized controlled trial.

BACKGROUND: Preliminary evidence suggests that coaching is an effective adjunct in resident training. The learning needs of faculty, however, are different from those of trainees. Assessing the effectiveness of peer coaching at improving the technical proficiency of practicing surgeons is an area that remains largely unexplored. The purpose of this study was to assess the efficacy of a peer coaching program that teaches laparoscopic suturing to faculty surgeons. METHODS: Surgeons inexperienced in laparoscopic suturing were randomized to either conventional training or peer coaching. Both groups performed a pretest on a box trainer. The conventional training group then received a web link to a tutorial for teaching laparoscopic suturing and a box trainer for independent practice. In addition to the web link and the box trainer, the peer coaching group received 2 half hour peer coaching sessions. Both groups then performed a stitch on the box trainer that was video recorded. The primary outcome measure was technical performance, which was assessed by a global rating scale. RESULTS: Eighteen faculty were randomized (conventional training n = 9; peer coaching n = 9). Initially, there was no difference in technical skills between the groups (conventional training median score 10 [interquartile range 8.5-15]; peer coaching 13 [10.5-14]; P = .64). After the intervention, the peer coaching group had improved technical performance (conventional training 11 [8.5-12.5]; peer coaching 18 [17-19]; P < .01). Comparing the pre- and postintervention scores within both groups, there was an improvement in technical proficiency in the peer coaching group, yet none in the conventional training group (before conventional training 10 [8.5-15], after conventional training 11 [8.5-12.5]; P = .56; before peer coaching 13 [10.5-14], after peer coaching 18 [17-19]; P < .01). CONCLUSION: This trial demonstrates that a structured peer coaching program can facilitate faculty surgeons learning a novel procedure.

Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes.

BACKGROUND: The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes. METHODS: This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted. RESULTS: Seventeen cases were identified. Patient age was 61 (range 34-75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4-3.9). Post-operative length of stay was 4 (4-6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8-2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2-30). Follow-up was 9.7 months (range 20 days-23 months), during which one patient developed recurrent disease. CONCLUSIONS: This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

Advanced training in laparoscopic abdominal surgery: a systematic review.

BACKGROUND: Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator. METHODS: Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles. RESULTS: Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid. CONCLUSION: Higher-quality studies are required to appraise educational value in this field.