Evaluation of the feasibility of a video-transmitted surgical ward round: a proof of concept study.

BACKGROUND: Surgical ward rounds are key element to point-of-care interprofessional postoperative treatment and technical and communicational aspects are relevant for the patient's safety and satisfaction. Due to COVID-19 restrictions, the training opportunity of experiencing a face-to-face surgical ward round was massively hampered and thus, we developed a digital concept. This study aims to investigate the feasibility of video-transmitted ward rounds integrating surgical and communicational aspects with live streaming from wards. Further, medical students were asked for their satisfaction and their subjective learning success. METHODS: The proof-of-concept study consisted of self-reported subjective evaluation of competences in ward round skills. Qualitative feedback was collected to gain deeper insight and students' empathy was rated by using the student version of the Jefferson Empathy Scale (JES). RESULTS: One hundred three medical students participated. The students were satisfied with the video-transmitted ward round (M = 3.54; SD = 1.22). In the subjective evaluation students' ward round competencies rose significantly (p < .001, Mpre = 3.00, SD = 0.77; Mpost = 3.76, SD = 0.75). The surgeon was rated as empathic (M = 119.05; SD = 10.09). In the qualitative feedback they named helpful aspects like including an expert for communication. However, they preferred the face-to-face setting in comparison to the digital concept. CONCLUSIONS: It was feasible to implement a video-transmitted ward round within a pandemic. The format worked technically, was well-accepted and also led to a subjective rise in the students' competencies. Video-transmitted ward rounds may be integrated to support the medical education, though, they cannot replace the face-to-face setting.

Impact of preoperative body mass index and weight loss on morbidity and mortality following colorectal cancer-a retrospective cohort study.

PURPOSE: Body weight and preoperative weight loss (WL) are controversially discussed as risk factors for postoperative morbidity and mortality in colorectal cancer surgery. The objective of this study is to determine whether body mass index (BMI) or WL is associated with a higher postoperative complication rate. METHODS: In this retrospective cohort study, data analysis of 1241 consecutive patients undergoing colorectal cancer surgery in an 11-year period was performed. The main outcome measures were wound infections (WI), anastomotic leakages (AL), and in-house mortality. RESULTS: A total of 697 (56%) patients with colon and 544 (44%) with rectum carcinoma underwent surgery. The rate of WI for each location increased with rising BMI. The threshold value was 28.8 kg/m2. Obese patients developed significantly more WI than normal-weight patients did following rectal resection (18.0% vs. 8.2%, p = 0.018). Patients with preoperative WL developed significantly more AL following colon resections than did patients without preoperative WL (6.2% vs. 2.5%, p = 0.046). In-house mortality was significantly higher in obese patients following colon resections than in overweight patients (4.3% vs. 0.4%, p = 0.012). Regression analysis with reference to postoperative in-house mortality revealed neither increased BMI nor WL as an independent risk factor. CONCLUSIONS: Increased preoperative BMI is associated with a higher WI rate. AL rate after colon resection was significantly higher in patients showing preoperative WL. Preoperative BMI and WL are therefore risk factors for postoperative morbidity in this study. Nevertheless, this has to be further clarified by means of prospective studies. Trial registration DRKS00025359, 21.05.2021, retrospectively registered.

Early postoperative endoscopic evaluation of rectal anastomoses: a prospective cross-sectional study.

BACKGROUND: Reported incidence of anastomotic leakage (AL) of rectal anastomoses is up to 29% with an overall mortality up to 12%. Nevertheless, there is no uniform evidence-based diagnostic procedure for early detection of AL. The objective of this prospective clinical trial was to demonstrate the diagnostic value of early postoperative flexible endoscopy for rectal anastomosis evaluation. METHODS: Flexible endoscopy between 5 and 8th postoperative day was performed consecutively in 90 asymptomatic patients. Sample size calculation was made using the two-stage Simon design. Diagnostic value was measured by management change after endoscopic evaluation. Anastomoses were categorized according to a new classification. Study is registered in German Clinical Trials Register (DRKS00019217). RESULTS: Of the 90 anastomoses, 59 (65.6%) were unsuspicious. 20 (22.2%) were suspicious with partial fibrin plaques (n = 15), intramural hematoma and/or local blood coagulum (n = 4) and ischemic area in one. 17 of these anastomoses were treated conservatively under monitoring. In three a further endoscopic re-evaluation was performed and as consequence one patient underwent endoscopic vacuum therapy. 11 (12.2%) AL were detected. Here, two could be treated conservatively under monitoring, four with endoscopic vacuum therapy and five needed revision surgery. No intervention-related adverse events occurred. A change in postoperative management was made in 31 (34.4%) patients what caused a significant improvement of diagnosis of AL (p < 0.001). CONCLUSIONS: Early postoperative endoscopic evaluation of rectal anastomoses is a safe procedure thus allows early detection of AL. Early treatment for suspicious anastomoses or AL could be adapted to avoid severe morbidity and mortality.

Evaluation of different setting configurations with a new developed telemedical interface of a parallel kinematic robotic system - An experimental development study.

BACKGROUND: For development of a minimally invasive intracorporal micromanipulator, a master-slave telemanipulation system was required. METHODS: Different input positions for a tablet-based input device with a heads-up centred screen were evaluated. Personal preference was assessed using a questionnaire. Then, the most ergonomic and intuitive position was compared to a surgical reference position based on laparoscopic sigmoid resection. RESULTS: After comparing a 45°, 75° (pitch) and 60°/20° (pitch/yaw) to a 60° reference position no significant differences in processing time and number of failures could be demonstrated. Study participants indicated the 60°/20° position as the most comfortable in the questionnaire. This was therefore compared with the laparoscopic reference position, both sitting and standing. Here, the laparoscopic sitting position was perceived to be the most ergonomic. CONCLUSIONS: The developed input device offers a maximum of flexibility and individualisation to reach ergonomic and intuitive conditions. General recommendations regarding an optimal setting cannot be given, based on our results.

Reducing Degrees of Freedom in Surgical Suturing: Implications for Minimally Invasive Device Development-A Prospective Experimental Study.

Open surgery allows the use of all 6 degrees of freedom (DOF; x-y-z and roll-pitch-yaw), whereas laparoscopy requires working under limitation to 4 axes. We present a prospective experimental study evaluating translational and rotational DOF restriction in surgical suturing tasks. An experimental platform included a kinematic structure that limited the maneuverability of the surgical instruments. The subjects (n=20) worked in a randomized order using (1) 6DOF, (2) 4DOF with 3 translational and 1 rotational DOF (4TRANS), and (3) 4DOF with 1 translational and 3 rotational DOF (4ROT). The time required to perform each task was recorded. Suturing and knot tying were significantly faster under 6DOF compared with 4ROT (both P<0.001) and 4TRANS (both P<0.001). Assessment of subjective difficulty and impairment showed most favorable results for 6DOF. The advantage of rotational compared with translational DOF should be considered in the development of future surgical devices.

Long-term results of the custom- made hip endoprostheses Evolution K® and Adaptiva®: A prospective cohort study.

The aim of our study is to evaluate clinical long-term results and determine changes in periprosthetic bone density of the custom-made hip prostheses Evolution-K ® and Adaptiva ® . Periprosthetic bone density were evaluated by means of DEXA (LunariDXA- Prodigy® bone densitometer) with a long-term follow-up of 16 (15-18) years (Evolution-K®) in 24 patients and 13 (13-15) years (Adaptiva®) in 41 patients. Evolution- K® had a survival rate of 92% and yielded 79/100 points in Harris Hip Score, a mediocre result. Adaptiva® had a survival rate of 99% and achieved a good score of 88/100 points. Bone density measurements demonstrated the greatest loss of bone density in the proximal regions of interest (ROI) for both prosthesis types (Evolution-K®: -25.8% ROI 1, -40.3% ROI 7; -8.3% ROI 2, -10.4% ROI 6; Adaptiva®: -29.8% ROI 7, -6.8% ROI 6, +14.3% ROI 3, +3.1% ROI 4). Adaptiva® yielded a good clinical result as compared to Evolution-K® with only average clinical results. Both prostheses clearly showed signs of "stress shielding". Here, the Adaptiva® achieved reduced bone density loss as compared to the Evolution-K®.

[Robotic Assisted Proctocolectomy with Ileal Pouch-Anal Anastomosis in a Case of Suspected Hereditary Polyposis]. / Roboterassistierte Proktokolektomie mit ileopouchanaler Anastomose bei Verdacht auf hereditäre Polyposis.

BACKGROUND: Various forms of hereditary polyposis have been described in the literature. Classical familial adenomatous polyposis (FAP) is a rare, autosomal dominantly inherited disease which is caused by a germline mutation in the adenomatous polyposis coli gene (APC). Patients with this diagnosis successively develop multiple polyps of the colon. Left untreated, FAP almost inevitably leads to malignant transformation. INDICATION: We present the case of a 37-year-old patient with histologically confirmed, stenotic adenocarcinoma of the descending colon and an initially suspected hereditary polyposis due to multiple polyps in the descending and sigmoid colon. METHODS: The video describes the preoperative imaging as well as endoscopic findings and demonstrates the technique of a two-stage, robotically assisted proctocolectomy with ileal pouch-anal anastomosis (IPAA) and the creation of a temporary loop ileostomy. CONCLUSIONS: With respect to the surgical treatment of classic FAP, restorative proctocolectomy (RPC) with ileal J-pouch construction can be regarded as an established standard procedure, despite controversy regarding various technical aspects. Minimally invasive strategies should be considered as an equivalent option compared to conventional techniques.

Learning curves, potential and speed in training of laparoscopic skills: a randomised comparative study in a box trainer.

BACKGROUND: The effectiveness of practical surgical training is characterised by an inherent learning curve. Decisive are individual initial starting capabilities, learning speed, ideal learning plateaus, and resulting learning potentials. The quantification of learning curves requires reproducible tasks with varied levels of difficulty. The hypothesis of this study is that the use of three-dimensional (3D) vision is more advantageous than two-dimensional vision (2D) for the learning curve in laparoscopic training. METHODS: Forty laparoscopy novices were recruited and randomised to a 2D Group and a 3D Group. A laparoscopy box trainer with two standardised tasks was used for training of surgical tasks. Task 1 was a positioning task, while Task 2 called for laparoscopic knotting as a more complex process. Each task was repeated at least ten times. Performance time and the number of predefined errors were recorded. 2D performance after 3D training was assessed in an additional final 2D cycle undertaken by the 3D Group. RESULTS: The calculated learning plateaus of both performance times and errors were lower for 3D. Independent of the vision mode the learning curves were smoother (exponential decay) and efficiency was learned faster than precision. The learning potentials varied widely depending on the corresponding initial values and learning plateaus. The final 2D performance time of the 3D-trained group was not significantly better than that of the 2D Group. The final 2D error numbers were similar for all groups. CONCLUSIONS: Stereoscopic vision can speed up laparoscopic training. The 3D learning curves resulted in better precision and efficiency. The 3D-trained group did not show inferior performance in the final 2D cycle. Consequently, we encourage the training of surgical competences like suturing and knotting under 3D vision, even if it is not available in clinical routine.

[Value of laparoscopy in blunt and penetrating abdominal trauma-a systematic review]. / Wertigkeit der Laparoskopie beim penetrierenden und stumpfen Abdominaltrauma ­ ein systematisches Review.

BACKGROUND: The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial. METHODS: A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice. RESULTS: A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases. CONCLUSION: By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.

Novel box trainer for taTME - prospective evaluation among medical students.

BACKGROUND: Transanal total mesorectal excision (taTME) has been subject to extensive research and increasing clinical application. It allows further reduction of trauma by accessing via a natural orifice. Manifold platforms and instruments have been introduced and heterogeneity in surgical techniques exists. Because of the technique's complexity there is a persistent need for dedicated training devices and concepts. MATERIALS AND METHODS: The key steps of taTME were analyzed and a box trainer with three modules resembling these steps was designed and manufactured. Twenty-one surgically inexperienced medical students performed five repetitions of the three tasks with the new box trainer. Time and error count were analyzed for assessment of a learning curve. RESULTS: A significant reduction of processing time could be demonstrated for tasks 1-3 (p < 0.001; p < 0.001; p = 0.001). The effect size was high for comparison of repetition 1 and 5 and decreased over the course (task 1: r = 0.88 vs. r = 0.21; task 2: r = 0.86 vs. r = 0.23; task 3: r = 0.74 vs. r = 0.44). Also, a significant reduction of errors was demonstrated for tasks 1 and 2. The decrease of effect size was analogously demonstrated. CONCLUSIONS: The trainer might help to reduce the use of animal models for testing of platforms and instruments as well as gaining first-hand experience in transanal rectal resection.

Robotic Versus Laparoscopic Sigmoid Resection for Diverticular Disease: A Single-Center Experience of 106 Cases.

Background: Laparoscopic sigmoid resection is the surgical standard for the treatment of diverticulitis. Robotic sigmoid resection with the da Vinci Xi® platform may offer advantages over the laparoscopic approach. Materials and Methods: One hundred and six patients with uncomplicated, complicated, or recurrent diverticular disease underwent robotic (n = 60) or laparoscopic (n = 46) sigmoid resection at our institution between 2013 and 2018. Patient demographics and characteristics, perioperative measures, and complications were retrospectively analyzed. Results: There were no statistically significant differences between the robotic and laparoscopic group with regard to operative time (130 versus 118 minutes; P = .23), anastomotic leakage (6.7% versus 6.5%; P = 1.0), need for stoma (6.7% versus 4.3%; P = 1.0), conversion rate (1.7% versus 0%; P = .36), reoperation (8.3% versus 15.2%; P = .27), overall complications according to the Clavien-Dindo classification (30.0% versus 30.4%; P = .8), mortality (1.7% versus 0%; P = 1.0), and need for intravenous analgesics (3.0 versus 2.1 days; P = .21). The duration of postoperative ileus was significantly shorter in the robotic group (2.2 versus 2.8 days; P = .01). Conclusion: Robotic sigmoid resection for uncomplicated, complicated, or recurrent diverticular disease is a safe and feasible procedure. However, robotic sigmoid resection for diverticulitis is not associated with relevant clinical benefits for patients compared to laparoscopic resection except for a slightly shorter duration of postoperative ileus.

[First Robotic Assisted Resection of a Retrorectal Tailgut Cyst - Video Case Report of a 27-Year-Old Female Patient]. / Roboterassistierte Resektion einer retrorektalen Tailgut-Zyste ­ erstbeschreibender Videofallbericht einer 27-jährigen Patientin.

PURPOSE: Tailgut cysts are a rare form of retrorectal tumours. They are also referred to as cystic hamartomas and predominantly affect female patients. Malignant transformation is thought to occur in 2 - 10% of cases, but there is scant further evidence. Besides the risk of malignant transformation, the feared complications include infection, difficulties in defecation, or potential dystocia necessitating in sano resection. INDICATION: We describe the case of a 27-year-old female patient presenting with a prolapsing round structure during defaecation. MRI, endosonography and transrectal drainage were carried out to exclude malignancy. We performed resection of the retrorectal tailgut cyst by robotic surgery. To the authors knowledge, this access has not previously been described for tailgut cyst resection. METHOD: Our video shows preoperative diagnostic testing, endoscopic drainage and robotic resection of the tailgut cyst. An intraoperative lesion of the dorsal rectum was successfully closed by suture. CONCLUSIONS: Different surgical techniques have been described for tailgut cyst resection. That with the widest application is posterior/sacral access, followed by abdominal and transrectal techniques. There are no published reports of robotic resection. We chose the robotic approach, as this is the surgeon's preferred technique for minimally invasive surgery of the pelvis.

Evaluation of self-educational training methods to learn laparoscopic skills - a randomized controlled trial.

BACKGROUND: Evaluation of two different self-educational methods (video assisted learning versus video assisted learning plus a nodal point operation primer) on learning laparoscopic suturing and intracorporal knotting. METHODS: Randomized controlled trial at the laparoscopic surgical training center, University of Tubingen with 45 surgical novices first year medical students being pretested for dexterity. After self-educational training for 90 min with either method (Group A: video assisted learning, Group B: video assisted learning plus a nodal point operation primer) participants had to perform five laparoscopic intracorporal knots. Assessed were number of knots completed (maximum of five knots counted, knot integrity, technical proficiency and knotting time per knot. Primary outcome measure is a composed knot score combining knot integrity, technical proficiency and knotting time. RESULTS: Group B (n = 23) achieved a significantly higher composed knot score than Group A (n = 22) (53.3 ± 8.4 versus 46.5 ± 13.6 points respectively, p = 0.016). Median knotting time per completed knot was significantly different between Group B and Group A (308 s [100-1221] versus 394 s [138-1397] respectively, p = 0.001). Concerning number of completed knots there was a trend towards more knots achieved in Group B (4.2 ± 1.2 versus 3.55 ± 1.4 respectively, p = 0.075) . CONCLUSIONS: The use of a nodal point operation primer highlighting essential key steps of a procedure augment the success of learning laparoscopic skills as suturing and intracorporal knotting. (UIN researchregistry3866, March 22, 2018).

Rapid thyroid nodule growth is not a marker for well-differentiated thyroid cancer.

BACKGROUND: Rapid growth of thyroid nodules is described as being associated with thyroid cancer. The objective of the study was to determine how the growth rate of thyroid nodules during follow-up is associated with the risk of thyroid cancer. METHODS: Retrospective analysis of patients undergoing thyroid surgery for nodular disease and a repetitive preoperative ultrasound work-up of at least 6 months was done. Nodule growth was considered relevant when a volume increase >49% was detected. Growth patterns were described as rapid for a volume increase present over 6 to 24 months. RESULTS: Of the 297 analysed patients, 226 (76%) displayed relevant nodule growth and 71 (24%) no relevant growth. A rapid growth pattern was seen in 73 patients (32%). Well-differentiated thyroid cancer was diagnosed in 33 patients (11%; 27 papillary, 6 follicular) with a relevant nodule growth in 2 and no relevant growth in 31 patients. No rapid growth pattern was observed in any case of well-differentiated thyroid cancer. A rapid growth pattern occurred only in benign nodules (70 patients) and in 1 patient each with a lymphoma, a metastasis of a renal cell cancer and a metastasis of a gastric adenocarcinoma. Therapy with levothyroxine and/or iodine was administered to 129 patients (43%) and was significantly inversely correlated with nodule growth (odds ratio 0.27; CI 95 % 0.14-0.53, p < 0.001). CONCLUSIONS: Thyroid nodule growth alone and especially a rapid growth pattern during follow-up for thyroid nodular disease is not a marker for well-differentiated thyroid cancer and should not be used as a stand-alone argument for thyroid surgery.

Diagnostic accuracy of hyperbilirubinaemia in anticipating appendicitis and its severity.

BACKGROUND: Hyperbilirubinaemia is reported to be a positive predictor in diagnosing appendicitis and especially appendiceal perforation. We, therefore, analysed the diagnostic accuracy of serum bilirubin in anticipating appendicitis and its severity. METHODS: All consecutive patients undergoing appendectomy for suspected appendicitis from May 2009 to August 2011 were analysed. Patients were classified based on final histopathological findings into the groups: no appendiceal inflammation, non-perforated appendicitis and perforated appendicitis. Primary outcome was the diagnostic accuracy of serum bilirubin levels in discriminating between no appendiceal inflammation and any appendicitis (perforated and non-perforated appendicitis) and non-perforated and perforated appendicitis. RESULTS: Of 493 analysed patients, 125 (25%) had no appendiceal inflammation, 312 (64%) had non-perforated appendicitis and 56 (11%) had perforated appendicitis. The proportion of patients with bilirubin elevation (>1.1 mg/dL) was different between those with no appendiceal inflammation (14%) and any appendicitis (36%) (p<0.0001), and between non-perforated appendicitis and perforated appendicitis 48% (p=0.04). However, the positive and negative likelihood ratios (LRs) for an elevated bilirubin were poor at discriminating the groups: no appendiceal inflammation versus any appendicitis (LR+ 2.62 (95% CI 1.65 to 4.16) and LR- 0.75 (95% CI 0.67 to 0.83)) and non-perforated appendicitis versus perforated appendicitis (LR+ estimate 1.74 (95% CI 1.28 to 2.38) and LR- 0.72 (95% CI 0.55 to 0.93)). CONCLUSIONS: Hyperbilirubinaemia is present in acute appendicitis but has a low diagnostic accuracy in discriminating between any appendicitis versus no appendiceal inflammation and perforated versus non-perforated appendicitis and is, therefore, of limited value in clinical routine. TRIAL REGISTRATION NUMBER: NCT01698099.