Trauma laparoscopy: A prospect of skills training (cohort study).

BACKGROUND: Diagnostic laparoscopy is well-accepted in management of penetrating abdominal trauma (PAT) with the rate of missed injuries below 1%. However, there is a reluctance to accept therapeutic laparoscopy in trauma society. The possible reason is a lack of laparoscopic skills by trauma surgeons. Moreover, no formal laparoscopy training program for trauma exists. The aim of this study was to interrogated our laparoscopy training particularly in trauma setting, and to investigate a possible relation between the seniority of surgeons performing the procedures and the complication rates. METHODS: All patients managed laparoscopically for PAT from January 2012 to December 2015 were analyzed. The seniority of operating surgeon was correlated with adverse outcomes, and with conversion. Surgeon-consultant (SC), assistant-consultant (AC), surgeon-senior-resident (SSR) and surgeon-junior-resident (SJC) groups were identified. Laparoscopic maneuvers used in this cohort were investigated and the set of essential laparoscopic skills was identified. The laparoscopic training program at our institution was described and discussed. RESULTS: Out of 283 patients with PAT approached with laparoscopy 33 (11.7%) were converted to laparotomy. Majority (49.6%) of laparoscopy was performed by senior resident. Consultant was an operating surgeon in 21.2% and an assistant in 8% of cases. Consultant was involved in cases with higher severity of injury and the complication rate was higher in the SC and AC groups. Essential laparoscopic skills were camera navigation, mobilization of intraabdominal organs, bowel run and intracorporeal suturing. During training, a senior resident was involved in 19% of operations for trauma. Trauma constituted 16% of all laparoscopy. CONCLUSION: Laparoscopy for trauma can be safely performed by residents under appropriate supervision. Laparoscopic skills should preferably be obtained during elective non-trauma procedures and transferred to trauma setting. Multimodal goal-directed, proctored training with regular assessments and feedback is effective and skills are transferable to trauma setting.

[Initial Experience with Uniportal Video-Assisted Thoracoscopic Surgery for Anatomical Lung Resections: A Propensity Score Study and an Observational Assessment of the Learning Curve]. / Uniportale videoassistiert-thorakoskopische anatomische Lungenresektionen: erste Erfahrungen und ein Vergleich mit dem multiportalen Zugang.

INTRODUCTION: Uniportal video-assisted thoracoscopic surgery (UVATS) for anatomical lung resections has gained popularity of late. This study aimed to elucidate the impediments to implementing the uniportal access method into the daily routine of VATS lung resections. To this end, we reviewed our initial experience and evaluated our progress. METHODS: From January to May 2016, 24 consecutive UVATS anatomical lung resections (UVATS group) were performed by a single surgeon without any previous experience in UVATS surgery. These cases were matched in a one-to-one fashion with a cohort of 102 patients who had undergone "classical" VATS anatomical lung resections (VATS group) in the past 2’years performed by the same surgeon, using the nearest estimated propensity score. Based on an initial analysis, the UVATS group was further divided into two subgroups, UVATS1 and UVATS2, consisting of the first and last 12 cases. RESULTS: No UVATS patient required conversion to thoracotomy or needed an additional port. The VATS group had a shorter mean operation time if compared with the UVATS1 subgroup (MVATS = 152, MUVATS1 = 191; p = 0.019), but not if compared with the UVATS2 subgroup (MVATS = 152, MUVATS2 = 152; p = 1). There was no difference between the groups in the number of lymph node stations sampled (MVATS = 7, MUVATS1 = 7, MUVATS2 = 7; p = 0.92), the average number of dissected lymph nodes (MVATS = 19, MUVATS1 = 15, MUVATS2 = 18; p = 0.659), and the number and type of postoperative complications. As demonstrated on an audio-analogue pain scale (AAS), the UVATS groups needed significantly less pain medication until discharge (p < 0.001). CONCLUSION: The adoption of uniportal VATS for anatomical lung resections can be accomplished without any impact on operative or clinical success, if performed by a surgeon already experienced in "classical" VATS. In our experience, there was no need for additional courses, proctored cases or modification of surgical instruments, although all options mentioned above may facilitate adoption.

Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies.

OBJECTIVE: To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. RESULTS: Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2, R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. CONCLUSION: OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula.

INTRODUCTION: There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes. AIMS: To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS: From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training. RESULTS: The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations. CONCLUSIONS: In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Critical appraisal of learning curve for single incision laparoscopic right colectomy.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) has emerged as a viable minimally invasive surgical approach with benefits and limitations yet to be fully elucidated. Although shown to be safe and feasible, characterization of the learning curve has not been addressed. Our aim was to identify a learning curve for SILC right hemicolectomy and to determine the incidence of operative failure and complication rates during this phase. METHODS: Over a 2-year period, data from 54 consecutive SILC cases performed by the same surgeon were tabulated in an institutional review board-approved database. A learning curve was generated utilizing cumulative sum (CUSUM) methodology to assess changes in total operative time (OT) across the case sequence. A separate learning curve was generated utilizing risk-adjusted CUSUM analysis, taking into account patient risk factors (i.e., age, American Society of Anesthesiologists score, body mass index, prior abdominal surgeries, and tumor size for malignant cases) and operative failure (i.e., prolonged OT, conversion to open surgery, intraoperative and 30-day postoperative complications, prolonged length of stay, reoperation, readmission, and mortality). RESULTS: Patients had a mean age of 63.6 ± 11.5 years, mean body mass index of 27.3 ± 3.9 kg/m(2), and median American Society of Anesthesiologists score of 2. Mean OT and length of stay were 123.5 ± 28.9 min and 3.9 ± 2.4 days, respectively. There were no conversions or oncologic failures. Six patients developed 30-day postoperative complications. CUSUM analysis of OT identified achievement of the learning phase after 30 cases. When taking into account both analyses, the rate of operative failure was not statistically different between the initial 30 and the final 24 cases. CONCLUSIONS: In our experience, the learning curve is achieved between 30 to 36 cases. Offering this minimally invasive surgical approach does not result in increased complications or harmful results even in the early phases of the learning curve.