Training and assessment for colorectal surgery and appendicectomy- a systematic review.

AIM: There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach. METHOD: A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported. RESULTS: Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery. CONCLUSION: This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

Online educational materials for appendectomy patients have good quality but poor readability.

BACKGROUND: Guidelines recommend patient health-related information be written at or below the sixth-grade level. This study evaluates the readability level and quality of online appendectomy patient education materials. METHODS: Webpages were evaluated using seven readability formulae: Flesh-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), Automated Readability Index (ARI), Simple Measure of Gobbledygook (SMOG), Flesch Reading Ease (FRE), and New Dale-Chall (NDC). Two evaluators assessed quality using the Brief DISCERN tool. RESULTS: Thirty seven webpages were analyzed. The mean readability scores were: FKGL = 9.11, GFI = 11.82, CLI = 10.84, ARI = 7.99, SMOG = 11.88, FRE = 51.17, and NDC = 5.48. 6 of the 7 readability formulae indicate that the materials were written at too high a level. The average Brief DISCERN score was 17.81, indicating good quality. CONCLUSIONS: Readability levels for online appendectomy patient education materials are higher than recommended but are of good quality. Authors of such materials should not only provide good quality information but also ensure readability.

Evaluation of surgical educational videos available for third year medical students.

Objectives: In this study we evaluated 40, top recommended, laparoscopic appendectomy and laparoscopic cholecystectomy videos located on public domain websites using eight criteria created by a panel of third year medical students and general surgeons. We hypothesized that there is a lack of quality, thorough educational laparoscopic surgical videos appropriate for third year medical students to review in preparation for the Surgery rotation.Methods: Utilizing a panel, which included four third year medical students and two general surgeons, we created an 'ideal medical student educational video checklist.' This checklist included 8 vital criteria. We selected 40, top recommended, videos available on YouTube and Google Video search engines, using 'laparoscopic cholecystectomy' and 'laparoscopic appendectomy' as key terms. Each video was evaluated by four third year medical students individually, using a binary system 'meets' or 'does not meet' each criterion. Individual scores were averaged, producing a single score for each video.Results: 0/40 (0%) of the videos met all eight of the criteria. 26/40 (65%) of the videos did not meet half of the criteria. The top performing videos 7/40 (17%) only met 5/8 criteria. Conclusions: We identified a lack of quality and thorough educational surgical videos appropriate for third year medical students and a need for improved online video based instruction. Our checklist can be utilized as a guide for anyone creating surgical videos for medical student education in the future.

Development of a structured virtual reality curriculum for laparoscopic appendicectomy.

BACKGROUND: Laparoscopic appendicectomy (LA) is a common surgical emergency procedure mainly performed by trainees. The aim was to develop a step-wise structured virtual reality (VR) curriculum for LA to allow junior surgeons to hone their skills in a safe and controlled environment. METHODS: A prospective randomized study was designed using a high-fidelity VR simulator. Thirty-five novices and 25 experts participated in the assessment and their performances were compared to assess construct validity. Learning curve analysis was performed. RESULTS: Five of the psychomotor tasks and all appendicectomy tasks showed construct validity. Learning was demonstrated in the majority of construct-valid tasks. A novel goal-directed VR curriculum for LA was constructed. CONCLUSIONS: A step-wise structured VR curriculum for LA is proposed with a framework which includes computer generated metrics and supports deliberate practice, spacing intervals, human instruction/feedback and assessment. Future study should test the feasibility of its implementation and transferability of acquired skill.

Implementation of a Surgical Simulation Care Pathway Approach to Training in Emergency Abdominal Surgery.

BACKGROUND: Simulation-based care pathway approach (CPA) training is a novel approach in surgical education. The objective of the present study was to determine whether CPA was feasible for training surgical residents and could improve efficiency in patients' management. A common disease was chosen: acute appendicitis. METHODS: All five junior residents of our department were trained in CPA: preoperative CPA consisted in virtual patients (VPs) presenting with acute right iliac fossa pain; intraoperative CPA involved a virtual competency-based curriculum for laparoscopic appendectomy (LAPP); finally, post-operative VP were reviewed after LAPP. Thirty-eight patients undergoing appendectomy were prospectively included before (n = 21) and after (n = 17) the training. All demographic and perioperative data were prospectively collected from their medical records, and time taken from admission to management was measured. RESULTS: All residents had performed less than 10 LAPP as primary operator. Pre- and intraoperative data were comparable between pretraining and post-training patients. Times to liquid and solid diet were significantly reduced after training [7 h (2-20) vs. 4 (4-6); P = 0.004, and 17 h (4-48) vs. 6 (4-24); P = 0.005] without changing post-operative morbidity [4 (19%) vs. 0 (0); P = 0.11] and length of stay [48 h (30-264) vs. 44 (21-145); P = 0.22]. CONCLUSIONS: CPA training is feasible in abdominal surgery. In the current study, it improved patients' management in terms of earlier oral intake.

Acquisition of Surgical Skills by Final-Year Medical Students in State-Owned Medical Schools of Cameroon: Are We Doing Any Good?

INTRODUCTION: World Health Organization recommends that basic surgical care be administered at the district level. In the absence of qualified surgeons, general practitioners are sometimes proposed to bridge the gap. Medical curricula in low- and middle-income countries must be designed accordingly. The aim of this study was to assess the achievements of training of undergraduate medical students in Cameroon towards meeting this objective. METHODS: A descriptive cross-sectional study was carried out in the four state-owned medical schools in Cameroon. All students who had completed all clinical rotations were assessed with a self-administered questionnaire for their exposure and self-perceived comfort in conducting some selected basic surgical skills and procedures. RESULTS: A total of 304 (87.6%) students returned filled questionnaires. Their self-perceived comfort in surgical skills ranged from 25% (manual node tying) to 86% (surgical scrubbing). Adequate exposure to selected surgical procedures was 87% for repair of perineal tear complicating vaginal delivery, above 80% for caesarean section and incision and drainage of abscess, 73% for cast immobilization of extremity fracture and just above 50% for hernia repair and appendectomy. It was as low as 3% for bowel resection and anastomosis. The choice to perform extra-curricular activity for skills improvement was significantly associated with adequate exposure (p < 0.05). CONCLUSION: Overall, the mastery of practical surgical skills and basic surgical interventions by final-year medical students in Cameroon is insufficient. There is need to reinforce the training and assessment by creating the conditions for an appropriate exposure of medical students during surgical rotations.

Safety in Allowing Residents to Independently Perform Appendectomy: A Retrospective Review.

BACKGROUND: In an era of competency-based education and concern about graduating resident readiness for practice, early resident autonomy and the ability to safely teach junior residents is becoming increasingly important. In this study, we aimed to understand the effect of "teaching resident" (2 residents operating under the supervision of an attending physician) appendectomy cases on outcomes. STUDY DESIGN: We performed a single-center retrospective review of 928 patients who underwent appendectomy within the University of Wisconsin hospital system, from October 2014 to December 2017. We examined how 2 residents (compared with 1 resident with an attending) attempting a case affected operation time, surgical site infection (SSI) rate, conversion to open rate, postoperative CT scanning, and readmission rate, while controlling for sex, age, American Society of Anesthesiologists (ASA) class, BMI, previous lower abdominal surgery, acuity, perforation, and presence of a junior attending. RESULTS: We identified 597 1-resident cases and 331 2-resident or "teaching resident" cases. We performed multiple logistic regression to assess teaching resident cases as a predictor of postoperative outcomes. There were no significant differences in postoperative surgical site infection (superficial or organ space) odds ratio (OR) = 0.83 (95% CI, 0.47, 1.45); p = 0.51, conversion to open OR = 1.10 (95% CI, 0.46, 2.60); p = 0.84, postoperative CT scanning OR = 0.82 (95% CI, 0.48, 1.35); p = 0.42, or readmission within 30 days OR = 0.76 (95% CI, 0.40, 1.44); p = 0.40. However, teaching resident operative times were more likely to be classified as prolonged OR = 1.44 (95% CI, 1.03, 2.01); p = 0.03. CONCLUSIONS: Senior surgical trainees can safely supervise more junior trainees performing appendectomy procedures, and training programs should encourage faculty to allow residents to not only manage operative appendicitis as independently as possible, but to supervise junior residents in the intraoperative management of appendicitis.

Prospective Cohort Study of Haptic Virtual Reality Laparoscopic Appendicectomy Learning Curve Trajectory.

Background: Simulation training is strongly advocated by 24/7 risk-rich professions because swift learning curve inflection point attainment delivers earlier competence; the left-shift effect. The aim of this study was to determine the value of haptic laparoscopic virtual reality simulation, by iterative benchmark exercise (n = 8), before simulated laparoscopic appendicectomy (SLA); the hypothesis was that favorable benchmark learning curve trajectories would be associated with improved SLA competence when compared with consultant expert performance. Methods: A 28-trainee cohort completed 1349 Laparoscopic Haptic Virtual Reality Skills (LHVRS) tasks, during which 19 ergonomic variables were assessed by virtual interface, including force feedback (Surgicalscience.com), before 153 SLAs. Primary outcome measure was SLA composite competence score related to six consultant trainer experts. Results: Of the eight LHVRS tasks, the three with the steepest learning curve trajectories correlated with better median overall SLA competence scores, namely tissue grasping/lifting (rho = 0.362, P = .049), fine dissection (rho = 0.388, P = .028), and camera navigation (rho = 0.518, P = .007); fine dissection was the only haptic laparoscopic virtual reality simulation task that predicted a SLA score within a Youden index defined, 70% of the consultant expert level (area under curve [AUC] = 0.803, P = .028). A significant SLA learning curve emerged, with a learning curve trajectory inflection point at the fourth SLA attempt (first SLA 30.5% versus fourth SLA score 76.0%, gradient 76°, P = .010). Conclusion: Learning curve trajectory can be measured, influenced, and accelerated significantly; a pronounced left-shift effect, with translational potential for enhanced shorter training time and improved patient safety.

Current Trends in Training in the Surgical Management of Acute Appendicitis at a Veteran Affairs Hospital.

INTRODUCTION: An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention. We hypothesized that the management of acute appendicitis has drastically changed from these previous practices. METHODS: A retrospective, single institution study was performed at the VA North Texas Health Care System between July 2005 to June 2017 for all patients who underwent an appendectomy. Using postgraduate year (PGY)-level (PGY 1-3 and PGY 4-5) as a dependent variable, univariate analyses, and multiple logistic regression analyses were performed. All statistical tests were 2-sided, and the statistical significance level was set at a p ≤ 0.05. RESULTS: Only patients with acute appendicitis were included (n = 257; male = 90.7%; age = 45.4 ± 15.6 year old; body mass index = 30.3 ± 6.3 Kg/m2). Of these, only 8 were performed by interns, 25 by PGY-2, 147 by PGY-3, 22 by PGY-4, and 55 by PGY-5. On presentation, 92.2% of patients had a computed tomography scan and 90.7% underwent a laparoscopic appendectomy. Conversion rate was 4.7%. There were 20 complications (7.8%) and length of hospital stay was 2.2±3.7 days. Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, body mass index, American Society of Anesthesiologists (ASA), and had similar WBC and blood pressure on initial presentation (all p's > 0.05); but were more likely to have diabetes mellitus, hypertension or pulmonary disease. Complication rate was the same (7.8%) for both senior and junior residents. CONCLUSIONS: At the VA North Texas Health Care System, most patients presenting with suspected appendicitis undergo a computed tomography scan. Most cases are performed laparoscopically mainly by PGY ≥ 3 residents. The rate of post-operative complications was similar between junior and senior residents.

Laparoscopic appendectomy - Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons.

AIM OF THE STUDY: Pediatric surgery trainees at our program are allowed to perform unsupervised laparoscopic appendectomies during their last year of training to promote independent operative decision-making skills. We reviewed the outcomes of laparoscopic appendectomies done by senior trainees without supervision and compared them to experienced pediatric surgeons. METHODS: We reviewed 500 laparoscopic appendectomies performed without supervision by the last 10 pediatric surgery trainees during their last year of training (first 50 cases of each trainee). We compared the outcomes of those 500 cases to the outcomes of 200 laparoscopic appendectomies performed by eight experienced pediatric surgeons (last 25 cases of each surgeon). Data are expressed as mean (SD), unless otherwise indicated. A P value of ≤0.05 was regarded as significant. MAIN RESULTS: Median age in the "trainees" and "surgeons" groups was 11 (range 2-22) and 12 (2-20) years, respectively (P = 0.35). The proportion of perforated appendicitis was similar: 98/500 (19.6%) in the trainees group and 42/200 (21%) in the surgeons group, respectively (P = 0.75). Mean operative time was 41 (SD 14.5) min in the trainees group vs. 39 (SD 16.1) min in the surgeons group (P = 0.05). Minor intraoperative complications occurred in 3/500 (0.6%) cases in the trainees group vs. 1/200 (0.5%) in the surgeons group (P = 0.69). No major complications occurred in either group. Mean hospital stay was 2 (range 0.5-26) and 2.3 (range 0.5-18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13/500 vs. 5/200 readmissions (P = 0.92), and 1/500 vs. 1/200 reoperations in the trainees and surgeons groups, respectively (P = 0.91). CONCLUSION: Allowing senior pediatric surgery trainees to perform laparoscopic appendectomies without supervision to stimulate surgical autonomy is safe and does not compromise patient outcomes. LEVEL OF EVIDENCE: III.

Impact of Resident-Performed Laparoscopic Appendectomy on Patient Outcomes and Safety.

BACKGROUND: Laparoscopic appendectomy is a training model for surgical residents to begin their surgical experience. However, there is concern about worse outcomes of surgery performed by inexperienced residents. We investigated surgical outcomes and patient safety in laparoscopic appendectomy performed by residents. MATERIALS AND METHODS: This is a retrospective cohort study of all consecutive patients operated on for acute appendicitis in a single tertiary hospital. A total of 971 patients who had laparoscopic appendectomy on an emergency basis between December 2010 and 2014 were analyzed. An attending, fellow, or resident with or without supervision performed the surgery. Surgical outcomes were compared among the four groups according to operator type. RESULTS: Laparoscopic appendectomy was successfully performed in 965 patients (99.4%) and was converted to open surgery in 6 patients. The conversion rate and incidence of complications were not different among the four groups. Operating time and length of hospital stay were significantly shorter in the attending group than in the fellow or resident groups, but did not differ between the fellow and resident groups. Unsupervised residents or fellows more often placed abdominal drainage than attending surgeons. Patients with drainage had a significantly longer hospital stay compared to patients without drainage (3.64 days versus 6.33 days, P ≤ .0001), as well as a longer mean time to gas passage (1.17 days versus 1.61 days, P ≤ .0001). CONCLUSIONS: Resident-performed laparoscopic appendectomy was safe, but was associated with significant prolongations in hospital stay and operation time. These differences were not clinically relevant with regard to complications.

Laparoscopic Appendectomy: Minimally Invasive Surgery Training Improves Outcomes in Basic Laparoscopic Procedures.

BACKGROUND: To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training. METHODS: Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded. RESULTS: A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32-60 vs. 58 min, IQR 44-81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001). CONCLUSIONS: MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.

Can laparoscopic appendectomy be safely performed by surgical residents without prior experience of open appendectomy?

BACKGROUND: As laparoscopic surgery has become the mainstream technique for abdominal surgery, it has become difficult for surgical residents to have opportunities to perform open surgery. This study aimed to examine the appropriateness and feasibility of laparoscopic appendectomy performed by surgical trainees who had little experience with open appendectomy or laparoscopic training with animal models. METHODS: We retrospectively reviewed all the records of patients who underwent appendectomy for acute appendicitis from April 2008 to December 2014. Residents were assigned to two levels of seniority: junior residents who had undergone 1-3 years of residency and senior residents who had undergone 4-6 years of residency. Patient characteristics, histopathological results, operative time, blood loss, conversion to open procedure, complications, length of hospital stay, and mortality were compared between the two groups. RESULTS: During the study period, 174 patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by junior residents and 90 patients were operated on by senior residents. There were no statistical differences in the characteristics of the patients, conversion rates (0/174 vs. 1/90), median operative times (75 minutes vs. 75 minutes), complication rates (7% vs. 4%), and median lengths of hospital stay (4 days vs. 4 days). CONCLUSION: Laparoscopic appendectomy can be performed safely by surgical residents who had little experience or training with animal models or open appendectomy. In this era of laparoscopic surgery, laparoscopic appendectomy represents an important opportunity for training surgical residents with little experience of open surgery.

Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy.

BACKGROUND: Proficiency-based virtual reality (VR) training curricula improve intraoperative performance, but have not been developed for laparoscopic appendicectomy (LA). This study aimed to develop an evidence-based training curriculum for LA. METHODS: A total of 10 experienced (>50 LAs), eight intermediate (10-30 LAs) and 20 inexperienced (<10 LAs) operators performed guided and unguided LA tasks on a high-fidelity VR simulator using internationally relevant techniques. The ability to differentiate levels of experience (construct validity) was measured using simulator-derived metrics. Learning curves were analysed. Proficiency benchmarks were defined by the performance of the experienced group. Intermediate and experienced participants completed a questionnaire to evaluate the realism (face validity) and relevance (content validity). RESULTS: Of 18 surgeons, 16 (89%) considered the VR model to be visually realistic and 17 (95%) believed that it was representative of actual practice. All 'guided' modules demonstrated construct validity (P < 0.05), with learning curves that plateaued between sessions 6 and 9 (P < 0.01). When comparing inexperienced to intermediates to experienced, the 'unguided' LA module demonstrated construct validity for economy of motion (5.00 versus 7.17 versus 7.84, respectively; P < 0.01) and task time (864.5 s versus 477.2 s versus 352.1 s, respectively, P < 0.01). Construct validity was also confirmed for number of movements, path length and idle time. Validated modules were used for curriculum construction, with proficiency benchmarks used as performance goals. CONCLUSION: A VR LA model was realistic and representative of actual practice and was validated as a training and assessment tool. Consequently, the first evidence-based internationally applicable training curriculum for LA was constructed, which facilitates skill acquisition to proficiency.

Assessment potential of a new suture simulator in laparoscopic surgical skills training.

BACKGROUND: The skills necessary for performing effective laparoscopic suturing are difficult to acquire; as a result, simulators for learning these skills are rapidly becoming integrated into surgical training. The aim of the study was to verify whether a new hybrid simulator has the potential to measure skill improvement in young, less experienced gastroenterological surgeons. MATERIAL AND METHODS: The study included 12 surgeons (median age, 29 (27-38)] years; 11 men (91.7%), one woman (8.3%)) who participated in a two-day laparoscopic training seminar. We used the new simulator before and after the program to evaluate individual performance. Skills were evaluated using five criteria: volume of air pressure leakage, number of full-thickness sutures, suture tension, wound area, and performance time. RESULTS: Air pressure leakage was significantly higher after than before the training (p = .027). The number of full-thickness sutures was significantly higher post-training (p < .01). Suture tension was significantly less post-training (p = .011). Wound opening areas were significantly smaller post-training (p = .018). Performance time was significantly shorter post-training (p = .032). CONCLUSIONS: Our study demonstrated the assessment quality of this new laparoscopic suture simulator.

Evaluation of Procedural Simulation as a Training and Assessment Tool in General Surgery-Simulating a Laparoscopic Appendectomy.

BACKGROUND: Laparoscopic appendectomy is a commonly performed surgical procedure, but few training models have been described for it. We examined a virtual reality module for practising a laparoscopic appendectomy. METHODS: A prospective cohort study with the following 3 groups of surgeons (n = 45): novices (0 procedures), intermediates (10-50 procedures), and experienced (>100 procedures). After being introduced to the simulator and 1 familiarization attempt on the procedural module, the participants practiced the module 20 times. Movements, task time, and procedure-specific parameters were compared over time. RESULTS: The time and movement parameters were significantly different during the first attempt, and more experienced surgeons used fewer movements and less time than novices (p < 0.01), although only 2 parameters were significantly different between novices and intermediates. All 3 groups improved significantly over 20 attempts (p < 0.0001). The intraclass correlation coefficient varied between 0.55 and 0.68 and did not differ significantly between the 3 groups (p > 0.05). When comparing novices with experienced surgeons, novices had a higher risk of burn damage to cecum (odds ratio [OR] = 3.0 [95% CI: 1.3; 7.0] p = 0.03), pressure damage to appendix (OR = 3.1 [95% CI: 2.0; 4.9] p < 0.0001), and grasping of the appendix (OR = 2.9 [95% CI: 1.8; 4.7] p < 0.0001). The risk of causing a perforation was not significantly different among the different experience levels (OR = 1.9 [95% CI: 0.9; 3.8] p = 0.14). Only 3 out of 5 error parameters differed significantly when comparing novices and experienced surgeons. Similarly, when comparing intermediates and novices, it was only 2 of the parameters that differed. DISCUSSION: The simulator module for practising laparoscopic appendectomy may be useful as a training tool, but further development is required before it can be used for assessment purposes. Procedural simulation may demonstrate more variation for movement parameters, and future research should focus on developing better procedure-specific parameters.

Single-Incision Laparoscopic Appendectomy by Surgical Trainees.

BACKGROUND: Single-incision laparoscopic appendectomy (SILA) is one of the most commonly performed single port surgeries in the world. However, there are few publications documenting a young resident's experience. The purpose of this study is to investigate clinical outcomes of SILA performed by a surgical trainee and to evaluate its feasibility and safety compared with conventional three-port laparoscopic appendectomy (TPLA) when performed by a surgical trainee and SILA by surgical staff. METHODS: Between September 2014 and August 2015, clinical data were retrospectively collected for SILA and TPLA cases performed at Chung-Ang University Hospital. Three surgical residents who have assisted at least 50 cases of TPLA and 30 cases of SILA performed by gastrointestinal surgery specialists performed the surgeries. The indication of SILA by surgical trainees was noncomplicated appendicitis with no comorbidity. RESULTS: In total, 47 patients underwent SILA by surgical residents, 98 patients underwent TPLA by surgical residents and 137 patients underwent SILA by surgical staff. In comparing SILA and TPLA performed by surgical residents, the mean age was younger (26 vs. 41 y, P<0.005) in the SILA group, the operative time (47.2 vs. 61.5 min, P<0.010) and hospital stay (2.3 vs. 2.7 d, P=0.003) were shorter in SILA group. In the SILA group, 2 cases of postoperative fluid collection (5.7%) occurred, necessitating antibiotic treatment. In TPLA group, 1 postoperative abscess occurred, requiring drainage. When comparing SILA performed by surgical residents and SILA performed by surgical staff, there were no significant differences in operation time, and postoperative complications. CONCLUSION: Surgical residents safely performed SILA with good postoperative outcomes after short learning curve.

Single-incision laparoscopic surgery as a teaching procedure: a single-center experience of more than 2100 procedures.

PURPOSE: To confirm the safety and feasibility of single-incision laparoscopic surgery (SILS) and to compare the patient outcomes of single-incision laparoscopic surgery for laparoscopic appendectomy (SILS-LA) performed by resident doctors vs. staff surgeons. METHODS: We performed a retrospective analysis of patients who underwent SILS between May, 2009 and May, 2015 at Osaka Police Hospital. RESULTS: We analyzed 2172 patients. The operations performed consisted of cholecystectomy (n = 598), appendectomy (n = 202), inguinal hernia repair (n = 301), colorectal surgery (n = 673), and gastrectomy (n = 398). SILS was performed safely for a wide range of procedures with acceptable conversion and perioperative complication rates. The resident doctors in our department operated safely on 77 % (156/202) of patients undergoing SILS-LA. The staff surgeons operated on more elderly patients and patients with complicated appendicitis than did the resident doctors. The operative outcomes of the resident-performed SILS-LAs were better than those of the staff surgeons, although there was a patient selection bias. CONCLUSIONS: SILS seems safe and feasible for a wide range of procedures. Based on our findings, we believe that SILS-LA could be a useful teaching procedure for resident doctors to perform on selected patients, under the guidance of an experienced staff surgeon.