Abdominal wall surgery units accreditation. The Spanish model.

The Spanish Association of Surgeons (AEC) deems it essential to define and regulate the acquisition of high-specialization competencies within General Surgery and Gastrointestinal Surgery and proposes the Regulation for the accreditation of specialized surgical units. The AEC aims to define specialized surgical units as those functional elements of the health system that meet the defined requirements regarding their provision, solvency, and specialization in care, teaching, and research. In this paper we present the proposed accreditation model for Abdominal Wall Surgery Units, as well as the results of a survey conducted to assess the status of such units in our country. The model presented represents one of the pioneering initiatives worldwide concerning the accreditation of Abdominal Wall Surgery Units.

Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA).

BACKGROUND: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe". METHODS: A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe". RESULTS: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. CONCLUSIONS: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety.

BACKGROUND: The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice. METHODS: A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. RESULTS: Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. CONCLUSIONS: A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Impact of tumor stage and neoadjuvant chemotherapy in fluorescence-guided lymphadenectomy during laparoscopic gastrectomy for gastric cancer: A propensity score-matched study in a western center.

BACKGROUND: The use of indocyanine green fluorescence has been shown to be a safe and effective method for improving lymph node retrieval in patients with gastric cancer. However, previous studies have focused on early-stage tumors and/or the Asian population and excluded patients who received neoadjuvant treatment. METHODS: In this study, 142 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy at a Spanish hospital between January 2017 and December 2022. Of these, 42 patients received preoperative indocyanine green injection to guide lymphadenectomy. Their outcomes were compared to a retrospective cohort of 42 patients after 1:1 propensity score matching. RESULTS: The feasibility of indocyanine green lymphatic mapping was 95.5%. No complications associated with indocyanine green injection were observed. The indocyanine green group had a significantly higher number of retrieved lymph nodes than the non-indocyanine green group (32.67 vs 25.14; P = .013). This statistically significant difference was maintained across subgroups of neoadjuvant treatment, non-obese patients, pT0 to 2 stage, and pN0 stage. In 47.6% of patients from the indocyanine green group, lymphadenectomy was extended outside the standard D2 dissection area based on indocyanine green uptake, but none of the retrieved lymph nodes were metastatic. There were no differences in postoperative complications and length of hospital stay between the 2 groups. CONCLUSION: Indocyanine green-guided lymphadenectomy is safe and feasible and increases the number of retrieved lymph nodes compared to conventional lymphatic dissection, as well as in patients receiving neoadjuvant chemotherapy. The use of indocyanine green should be routine if available for guiding lymph node dissection in gastric cancer, regardless of tumor stage or previous neoadjuvant treatment. However, further studies are needed to determine the impact of this technique on disease-free and overall survival.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

RAWS4all project: validation of a new silicone model for robotic TAPP inguinal hernia repair.

BACKGROUND: Trans-abdominal pre-peritoneal (TAPP) hernia repair is a complex procedure that presents several challenges. Even though, due to the high prevalence of inguinal hernia, TAPP technique is increasing in frequency and robotic Abdominal Wall Surgery (rAWS) is emerging as a valuable tool in this regard. Although inguinal TAPP procedure principles have been published and simulation is needed, the availability of validated models remains scarce. METHODS: A new low-cost model was developed to simulate inguinal rTAPP repair. For validity assessment, a new TAPP-specific fidelity questionnaire and assessment scale were developed to compare the performance of novices and experts in the simulated procedure. The models used were assessed at 60 min for execution and quality score. RESULTS: Twenty-five residents and specialists from all over the country participated in this study. Execution, quality, and global performance was higher in the seniors group compared to juniors (8.91 vs 6.36, p = 0.02; 8.09 vs 5.14, p < .001; and 17 vs. 11,5, p < .001, respectively). Overall fidelity was assessed as being very high [4.41 (3.5-5.0), α = .918] as well as face [4.31 (3.0-5.0), α = .867] and content validity [4.44 (3.2-5.0), α = .803]. Participants strongly agreed that the model is adequate to be used with the DaVinci® Robot [4.52 (3.5-5.0), α = .758]. CONCLUSION: This study shows face, content, and construct validity of the model for inguinal TAPP simulation, including for robotic surgery. Therefore, the model can be a valuable tool for learning, understanding, practicing, and mastering the TAPP technique prior to participating in the operating room.

Classification of GIST and other benign gastric tumors based on minimally invasive surgical strategy.

PURPOSE: Gastrointestinal mesenchymal tumors (GMTs) include malignant, intermediate malignancy, and benign lesions. The aim is to propose a new surgical classification to guide the intraoperative minimally invasive surgical strategy in case of non-malignant GMTs less than 5 cm. METHODS: Primary endpoint is the creation of a classification regarding minimally invasive surgical technique for these tumors based on their gastric location. Secondary endpoint is to analyze the R0 rate and the postoperative morbidity and mortality rates. Tumors were classified in two groups based on their morphology (group A: exophytic, group B: transmural/intragastric). Each group is then divided based on the tumor location and consequently surgical technique used in subgroup: AI (whole stomach area) and AII (iuxta-cardial and pre-pyloric areas) both for the anterior and posterior gastric wall; BIa (greater curvature on the anterior and posterior wall), BIb (lesser curvature on the anterior wall); BII (iuxta-cardial and pre-pyloric area in the anterior and posterior wall, including the lesser curvature on the posterior wall). RESULTS: Forty-two patients were classified and allocated in each subgroup: 17 in AI, 2 in AII, 5 in BIa, 3 in BIb, and 15 in BII. Two postoperative Clavien-Dindo I complications (4.8%, subgroup BIa and BIb) occurred. One patient (2.4%, subgroup AI) underwent reintervention due to R0 resection. CONCLUSIONS: This classification proved to be able to classify gastric lesions based on their morphology, location, and surgical treatment, obtaining encouraging perioperative results. Further studies with wider sample of patients are required to draw definitive conclusions.

Is laparoscopic TAPP the preferred approach for the treatment of inguinal hernia? Technique, indications and future perspectives.

The repair of inguinal hernia is one of the most frequently performed surgeries in General Surgery units. The laparoscopic approach for these hernias will be clearly considered as the gold standard, based on its advantages over the open approach. There are no clear advantages of the transabdominal preperitoneal approach (TAPP) over the totally preperitoneal approach (TEP), although it has been shown to be more reproducible, presenting a shorter learning curve, although it presents more possibilities of developing trocar site hernias. Laparoscopic TAPP could be superior to TEP in the following indications: incarcerated hernias, emergencies, previous preperitoneal surgery, previous Pfanestiel-type incision, recurrent hernias, inguinoscrotal hernias and obese, being also a better alternative for females. Robotic TAPP is a safe approach with similar results to laparoscopy; however, it is related to an increase in costs and operating time. The value of this technology for the repair of complex hernias (multiple recurrences, inguino-scrotal or after previous preperitoneal surgery) remains to be determined, since they represent a certain challenge for the conventional laparoscopic approach. On the other hand, robotic repair of inguinal hernias may be a way to reduce the learning curve before addressing complex ventral hernias. Finally, artificial intelligence applied to the laparoscopic approach to inguinal hernia will undoubtedly have a significant impact in the future especially to determine the best the indications for this approach, on the performance of a safer technique, on the correct selection of meshes and fixation mechanisms, and on learning curve.

Gastrostomies: experience and complications with three modalities in a tertiary centre over a 26-year period.

Objectives: To describe the complications associated with the different gastrostomy techniques [endoscopic (PEG), radiologic (PRG), and surgical (SG)] performed in the last 26 years in a terciary hospital. Methods: Retrospective observational study. Patients who underwent gastrostomy at the Virgen del Rocío University Hospital between 1995 and 2021 were included. For PEG, the PULL technique was performed until 2018 and subsequently the PUSH technique predominantly. For PRG, a pigtail catheter was used until 2003, a balloon catheter between 2003 and 2009, and a balloon catheter with gastropexy between 2015 and 2021. For SG, the conventional technique (CSG) was performed until 2009 and since then the laparoscopic assisted percutaneous gastrostomy (PLAG) technique. Descriptive analysis was performed obtaining the median and quartiles of the quantitative variables [P50 (P25-P75)] and the frequency for the qualitative variables [n (%)].The comparison of complications between patients who underwent different techniques was performed with Fisher's test. Results: n = 1,070 (PEG = 608, PRG = 344, SG = 118). The three most frequent indications were head and neck tumors, neurological diseases and gastroesophageal tumors. The percentage of patients who had any complication was 48.9% (PEG-PULL), 23.7% (PEG-PUSH), 38.5% (pigtail PRG), 39.2% (balloon PRG), 29.7% (balloon with gastropexy PRG), 87.3% (CSG), and 41.26% (PLAG). 2 (0.18%) patients died from gastrostomy-related complications. 18(1.68%) presented with peritonitis and 5 (0.4%) presented with gastrocolic fistula. The rest of the complications were minor. Conclusion: Gastrostomy in any of its modalities is currently a safe procedure with a low rate of complications, most of which are minor.

EAES, SAGES, and ESCP rapid guideline: bowel preparation for minimally invasive colorectal resection.

BACKGROUND: Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline. OBJECTIVE: The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej . CONCLUSION: This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders. Guideline registration number PREPARE-2023CN045.

Update of the international HerniaSurge guidelines for groin hernia management.

BACKGROUND: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. METHOD: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. RESULTS: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. CONCLUSION: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Full endoscopic minimally invasive extraperitoneal modified Sugarbaker approach for para-colostomy hernia repair: Technical aspects and 2-year follow-up results of a prospective cohort.

AIM: This study aimed to assess technical aspects and clinical results of a new minimally invasive technique in parastomal hernia (PSH) repair, full endoscopic retromuscular access, after 2 years of follow-up. METHODS: Data from consecutive patients requiring minimally invasive ventral PSH repair were collected from 2019 to 2022. The inclusion criteria were patients aged between 18 and 80 years old with symptomatic PSH. Demographics and perioperative and postoperative data were collected. Postoperative pain and functional recovery were compared with preoperative data. RESULTS: Twelve patients with symptomatic PSH were included. The mean PSH defect area was 16.2 cm2 and the mean midline defect was 8.7 cm2 . No intra-operative complications or conversion to open surgery were detected. One patient (8%) required postoperative readmission due to partial bowel obstruction symptoms that required catheterization of the stoma. Pain significantly worsened after the first postoperative day compared to preoperative data but improved after the first postoperative month compared to the first postoperative week and after the 90th postoperative day compared to the first postoperative month, with significant differences. Significant restriction improvement was identified when 30 days after surgery data were compared to preoperative data and when the 180th postoperative day results were compared to 30 days after surgery. The average follow-up was 29 months. During the follow-up no clinical or radiological recurrence was observed. CONCLUSION: This paper shows low rate of intra- and postoperative complications with significant improvement in terms of pain activities restriction compared to preoperatory. After 29 months follow-up, no recurrence was identified, confirming that this approach offers good mid-term results.

Diverticulitis, surgery, evidence-based medicine, and the Steve Jobs' dots: a narrative review.

PURPOSE: Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. METHODS: Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. RESULTS: In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". CONCLUSIONS: Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management.

Fluorescence-based sentinel lymph node mapping and lymphography evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

BACKGROUND: The identification of metastatic lymph nodes is one of the most important prognostic factors in gastrointestinal (GI) cancers. Near-infrared fluorescence (NIRF) imaging has been successfully used in GI tumors to detect the lymphatic pathway and the sentinel lymph node (SLN), facilitating fluorescence image-guided surgery (FIGS) with the purpose to achieve a correct nodal staging. The aim of this study was to analyze the current results of NIRF SLN navigation and lymphography through data collected in the EURO-FIGS registry. METHODS: Prospectively collected data regarding patients and ICG-guided lymphadenectomies were analyzed. Additional analyses were performed to identify predictors of metastatic SLN and determinants of fluorescence positivity and nodal metastases outside the boundaries of standard lymphadenectomies. RESULTS: Overall, 188 patients were included by 18 surgeons from 10 different centers. Colorectal cancer was the most reported pathology (77.7%), followed by gastric (19.1%) and esophageal tumors (3.2%). ICG was injected with higher doses (p < 0.001) via extraparietal side (63.3%), and with higher volumes (p < 0.001) via endoluminal side (36.7%). Overall, NIRF SLN navigation was positive in 75.5% of all cases and 95.5% of positive SLNs were retrieved, with a metastatic rate of 14.7%. NIRF identification of lymph nodes outside standard lymphatic stations occurred in 52.1% of all cases, 43.8% of which were positive for metastatic involvement. Positive NIRF SLN identification was an independent predictor of metastasis outside standard lymphatic stations (OR = 4.392, p = 0.029), while BMI independently predicted metastasis in retrieved SLNs (OR = 1.187, p = 0.013). Lower doses of ICG were protective against NIRF identification outside standard of care lymphadenectomy (OR = 0.596, p = 0.006), while higher volumes of ICG were predictive of metastatic involvement outside standard of care lymphadenectomy (OR = 1.597, p = 0.001). CONCLUSIONS: SLN mapping helps identifying potentially metastatic lymph nodes outside the boundaries of standard lymphadenectomies. The EURO-FIGS registry is a valuable tool to share and analyze European surgeons' practices.