High amylase concentration in drainage liquid can early predict proximal and distal intestinal anastomotic leakages: A prospective observational study.

Background: Anastomotic leak (AL) is a serious complication in digestive surgery. Early diagnosis might allow clinicians to anticipate appropriate management. The aim of this study was to assess the predictive value of amylase concentration in drain fluid for the early diagnosis of digestive tract AL. Materials and Methods: Hundred and fourteen consecutive patients "at risk" of AL, in whom a flexible drainage was placed by surgeon's choice after digestive anastomosis were included. Patients with eso-gastric, bilio-digestive, and pancreatic anastomoses were excluded. Drain amylase measurement (DAM) was routinely performed on postoperative day (POD) 1, 3, 5-7. DAM values were compared between patients with postoperative AL versus patients without AL. A receiver-operating curve (ROC) with calculation of the areas under the ROC curves area under curves was performed and a cutoff value of DAM was calculated. Results: AL occurred in 25 patients (AL group) and 89 patients did not present AL (C group). The mean DAM was significantly higher in AL group versus C Group on POD 1, 3, and 5. A cutoff value of 307 IU/L predicted the occurrence of AL with a sensitivity and specificity of 91% and 100%, respectively. Positive and negative predictive values were 100% and 97.5%, respectively. Patients with AL had an elevated DAM prior to the appearance of any clinical signs of AL. Conclusion: High level DAM could accurately predict AL for proximal and distal digestive tract anastomoses. This simple, noninvasive, and low-cost method can accurately predict early AL and help physicians to perform appropriate imaging and treatment.

Concurrent, face, content, and construct validity of the RobotiX Mentor simulator for robotic basic skills.

OBJECTIVES: To assess several criteria, such as concurrent, face, content, and construct validity of the RobotiX Mentor (RXM) simulator for basic robotic skills and to compare virtual and actual dry lab dome. METHODS: A prospective study was conducted from December 2017 to May 2018 using RXM and a da Vinci Si robot. 37 subjects, divided into three groups according to their initial surgical training (expert, intermediate, and novice), were evaluated in terms of six representative exercises of basic robotic specific skills as recommended by the fundamentals of robotic surgery. RESULTS: There was a correlation between the automatic data from the RXM and the subjective evaluation with the robot. The face and content validity, which were evaluated by the experts, were generally considered high (71.5% and 62.5%, respectively). Three levels (analysis of variance [ANOVA]; P = .01) and two levels (P = .001) of experience were clearly identified by the simulator. CONCLUSION: Our study proves the concurrent validity and confirms the face, content, and construct validity of the RXM.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse.

INTRODUCTION: Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence. DESIGN: Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center. METHODS: Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery. RESULTS: During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related. CONCLUSIONS: In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Exploration of peripancreatic lymphatic pathways in a live porcine model.

Pancreatic cancer is associated with a poor prognosis, mainly due to lymph node invasion and lymph node recurrence after surgical resection, even after extended lymphadenectomy. The peripancreatic lymphatic system is highly complex and the specific lymphatic drainage of each part of the pancreas has not been established. The aim of this study was to determine the lymphatic drainage pathways specific to each part of the pancreas on live pigs using Patent Blue. The pancreases of 14 live pigs were injected in different parts of the gland. The technique was efficient and reproducible. The diffusion patterns were similar for each location and were reported. Our results in pigs allowed us to define specific nodal relay stations and lymphatic drainage for each part of the pancreas and confirm that independent anatomical-surgical pancreatic segments can be described. It is interesting to note that lymphatic drainage for the upper part of the proximal part of pancreas (duodenal lobe) occurred on the left side of the portal vein. This suggests that lymph node resection during cephalic duodenopancreatectomy in humans should be extended to the left side of the mesenteric vein, and probably to the right side of the superior mesenteric artery, as recently suggested. These results could help surgeons perform safe anatomical-segmental pancreatic resections with accurate lymphadenectomies and improve survival in patients with pancreatic cancer. Based on these results we will perform an innovative prospective study. Patent Blue will be injected into different parts of the gland in patients operated for pancreatic resection, and lymphatic diffusion of the dye will be recorded in relation to their origin from the theoretical pancreatic segments (ClinicalTrials.gov Identifier: NCT03597230).

Face and content validity of Xperience™ Team Trainer: bed-side assistant training simulator for robotic surgery.

In robotic surgery, the coordination between the console-side surgeon and bed-side assistant is crucial, more than in standard surgery or laparoscopy where the surgical team works in close contact. Xperience™ Team Trainer (XTT) is a new optional component for the dv-Trainer® platform and simulates the patient-side working environment. We present preliminary results for face, content, and the workload imposed regarding the use of the XTT virtual reality platform for the psychomotor and communication skills training of the bed-side assistant in robot-assisted surgery. Participants were categorized into "Beginners" and "Experts". They tested a series of exercises (Pick & Place Laparoscopic Demo, Pick & Place 2 and Team Match Board 1) and completed face validity questionnaires. "Experts" assessed content validity on another questionnaire. All the participants completed a NASA Task Load Index questionnaire to assess the workload imposed by XTT. Twenty-one consenting participants were included (12 "Beginners" and 9 "Experts"). XTT was shown to possess face and content validity, as evidenced by the rankings given on the simulator's ease of use and realism parameters and on the simulator's usefulness for training. Eight out of nine "Experts" judged the visualization of metrics after the exercises useful. However, face validity has shown some weaknesses regarding interactions and instruments. Reasonable workload parameters were registered. XTT demonstrated excellent face and content validity with acceptable workload parameters. XTT could become a useful tool for robotic surgery team training.

Effectiveness of an Integrated Video Recording and Replaying System in Robotic Surgical Training.

OBJECTIVE: This study evaluated the effectiveness of using a video recording and replaying system in robotic surgical training. SUMMARY BACKGROUND DATA: Robotic surgical videos are reviewed to accelerate the acquisition of robotic surgical skills. However, few professional recording and replaying systems have been used during robotic surgical training. The effectiveness of these professional video systems should be investigated and validated. METHODS: A randomized study was conducted to analyze the performance of 60 participants, who were unfamiliar with surgical robotics, in a robotic simulator. Participants were enrolled in 2 groups to perform 2 exercises on a Mimic dV-Trainer. One group was trained with the new protocol based on a recording and replaying system (controller of events on simulator and robot) and the other group was trained with the conventional method. The overall scores were automatically evaluated by the simulator. The number of additional requests for reviewing the videos or watching the trainer's demonstration and the learning curves based on the overall scores were compared between the 2 groups. RESULTS: The group trained with controller of events on simulator and robot presented a significantly improved learning curve in both exercises (P < 0.001) with more additional requests (P < 0.001) in comparison with the group trained with the conventional method. CONCLUSIONS: In robotic skills training, the use of a recording and replay system is beneficial and more efficient than the conventional training method.

"Alarm-corrected" ergonomic armrest use could improve learning curves of novices on robotic simulator.

BACKGROUND: In robotic surgery, the professional ergonomic habit of using an armrest reduces operator fatigue and increases the precision of motion. We designed and validated a pressure surveillance system (PSS) based on force sensors to investigate armrest use. The objective was to evaluate whether adding an alarm to the PSS system could shorten ergonomic training and improve performance. STUDY DESIGN: Twenty robot and simulator-naïve participants were recruited and randomized in two groups (A and B). The PSS was installed on a robotic simulator, the dV-Trainer, to detect contact with the armrest. The Group A members completed three tasks on the dV-Trainer without the alarm, making 15 attempts at each task. The Group B members practiced the first two tasks with the alarm and then completed the final tasks without the alarm. The simulator provided an overall score reflecting the trainees' performance. We used the new concept of an "armrest load" score to describe the ergonomic habit of using the armrest. RESULTS: Group B had a significantly higher performance score (p < 0.001) and armrest load score (p < 0.001) than Group A from the fifth attempt of the first task to the end of the experiment. CONCLUSIONS: Based on the conditioned reflex effect, the alarm associated with the PSS rectified ergonomic errors and accelerated professional ergonomic habit acquisition. The combination of the PSS and alarm is effective in significantly shortening the learning curve in the robotic training process.

Face, content, construct, and concurrent validity of a novel robotic surgery patient-side simulator: the Xperience™ Team Trainer.

OBJECTIVES: To determine the face, content, construct, and concurrent validity of the Xperience™ Team Trainer (XTT) as an assessment tool of robotic surgical bed-assistance skills. METHODS: Subjects were recruited during a robotic surgery curriculum. They were divided into three groups: the group RA with robotic bed-assistance experience, the group LS with laparoscopic surgical experience, and the control group without bed-assistance or laparoscopic experience. The subjects first performed two standard FLS exercises on a laparoscopic simulator for the assessment of basic laparoscopic skills. After that, they performed three virtual reality exercises on XTT, and then performed similar exercises on physical models on a da Vinci(®) box trainer. RESULTS: Twenty-eight persons volunteered for and completed the tasks. Most expert subjects agreed on the realism of XTT and the three exercises, and also their interest for teamwork and bed-assistant training. The group RA and the group LS demonstrated a similar level of basic laparoscopic skills. Both groups performed better than the control group on the XTT exercises (p < 0.05). The performance superiority of the group RA over LS was observed but not statistically significant. Correlation of performance was determined between the tests on XTT and on da Vinci(®) box trainer. CONCLUSIONS: The introduction of XTT facilitates the training of bedside assistants and emphasizes the importance of teamwork, which may change the paradigm of robotic surgery training in the near future. As an assessment tool of bed-assistance skills, XTT proves face, content, and concurrent validity. However, these results should be qualified considering the potential limitations of this exploratory study with a relatively small sample size. The training modules remain to be developed, and more complex and discriminative exercises are expected. Other studies will be needed to further determine construct validity in the future.

Effect of latency training on surgical performance in simulated robotic telesurgery procedures.

BACKGROUND: The effect of telesurgical training was evaluated at two latency levels. METHODS: Eleven subjects were randomly assigned to two delay groups (400 and 600 ms). Each group trained with latency on a simple task of dV-Trainer® and performed a difficult task before (pre-test) and after (post-test) the training. The follow-up was conducted 1 week after the training. RESULTS: The difficulty decreased gradually during training for both groups, while the task completion time and the instrument motion improved only in the 600 ms group. Both groups made progress from pre- to post-test, but statistical significance was not achieved. In the follow-up, subjects maintained their highest level achieved during training. CONCLUSIONS: Latency training is effective and this effect lasts at least 1 week. Latency training on a simple task may improve results in complex procedures. However, attention should be paid to avoiding carelessness due to confidence from training. Copyright © 2014 John Wiley & Sons, Ltd.

Relative contribution of haptic technology to assessment and training in implantology.

BACKGROUND: The teaching of implant surgery, as in other medical disciplines, is currently undergoing a particular evolution. AIM OF THE STUDY: To assess the usefulness of haptic device, a simulator for learning and training to accomplish basic acts in implant surgery. MATERIALS AND METHODS: A total of 60 people including 40 third-year dental students without knowledge in implantology (divided into 2 groups: 20 beginners and 20 experiencing a simulator training course) and 20 experienced practitioners (experience in implantology >15 implants) participated in this study. A basic exercise drill was proposed to the three groups to assess their gestural abilities. RESULTS: The results of the group training with the simulator tended to be significantly close to those of the experienced operators. CONCLUSION: Haptic simulator brings a real benefit in training for implant surgery. Long-term benefit and more complex exercises should be evaluated.

Toward a realistic simulation of organ dissection.

Whilst laparoscopic surgical simulators are becoming increasingly realistic they can not, as yet, fully replicate the experience of live surgery. In particular tissue dissection in one task that is particularly challenging to replicate. Limitation of current attempts to simulate tissue dissection include: poor visual rendering; over simplification of the task and; unrealistic tissue properties. In an effort to generate a more realistic model of tissue dissection in laparoscopic surgery we propose a novel method based on task analysis. Initially we have chosen to model only the basic geometrics of this task rather than a whole laparoscopic procedure. Preliminary work has led to the development of a real time simulator performing organ dissection with a haptic thread at 1000Hz. A virtual cutting tool, manipulated through a haptic device, in combination with 1D and 2D soft-tissue models accuratelyreplicatetheprocessoflaparoscopictissuedissection.

Determination of the latency effects on surgical performance and the acceptable latency levels in telesurgery using the dV-Trainer(®) simulator.

BACKGROUND: The primary limitation of telesurgery is the communication latency. Accurate and detailed data are lacking to reveal the latency effects on surgical performance; furthermore, the maximum acceptable latency in telesurgery remains unclear. METHODS: Sixteen medical students performed an energy dissection exercise and a needle-driving exercise on the robotic simulator dV-Trainer(®), and latencies varying between 0 and 1,000 ms with a 100-ms interval were randomly and blindly presented. Task completion time, instrument motion, and errors were automatically recorded. The difficulty, security, precision, and fluidity of manipulation were self-scored by subjects between 0 and 4 (0 the best, 2 moderate, and 4 the worst). RESULTS: Task completion time, motion, and errors increased gradually as latency increased. An exponential regression was fit to the mean times and motions (R (2) > 0.98). Subjective scorings of the four items were similar. The mean scores were less than 1 at delays ≤200 ms, then increased from 1 to 2 at 300-700 ms, and finally approached 3 at delays above. In both exercises, latencies ≤300 ms were judged to be safe by all and 400-500 ms were accepted by 66-75 % of subjects. Less than 20 % of subjects accepted delays ≥800 ms. CONCLUSIONS: The surgical performance deteriorates in an exponential way as the latency increases. The delay impact on instrument manipulation is mild at 0-200 ms, then increases from small to large at 300-700 ms, and finally becomes very large at 800-1,000 ms. Latencies ≤200 ms are ideal for telesurgery; 300 ms is also suitable; 400-500 ms may be acceptable but are already tiring; and 600-700 ms are difficult to deal with and only acceptable for low risk and simple procedures. Surgery is quite difficult at 800-1,000 ms, telementoring would be a better choice in this case.

Prior experience in micro-surgery may improve the surgeon's performance in robotic surgical training.

SUMMARY BACKGROUND DATA: Robotic surgery has witnessed a huge expansion. Robotic simulators have proved to be of major interest in training. Some authors have suggested that prior experience in micro-surgery could improve robotic surgery training. OBJECTIVE: To test micro-surgery as a new approach in training, we proposed a prospective study comparing the surgical performance of micro-surgeons with that of general surgeons on a robotic simulator. METHODS: 49 surgeons were enrolled; 11 in the micro-surgery group (MSG); 38 n the control group (CG). Performance was evaluated based on five dV-Trainer® exercises. RESULTS: MSG achieved better results for all exercises including exercises requiring visual evaluation of force feed-back, economy of motion, instrument force and position. CONCLUSIONS: These results show that experience in micro-surgery could significantly improve surgeons' abilities and their performance in robotic training. So, as micro-surgery practice is relatively cheap, it could be easily included in basic robotic surgery training.

Long-term outcomes of robot-assisted laparoscopic rectopexy for rectal prolapse.

BACKGROUND: Robot-assisted laparoscopic rectopexy for total rectal prolapse is safe and feasible. Small series proved clinical and functional short-term results comparable with conventional laparoscopy. No long-term results have been reported yet. OBJECTIVE: The primary objective of the study was to evaluate long-term functional and anatomic results of robot-assisted laparoscopic rectopexy. The secondary objective was to evaluate the learning curve of this procedure. DESIGN: Monocentric study data, both preoperative and perioperative, were collected prospectively, and follow-up data were assessed by a telephone questionnaire. SETTINGS: The study was performed in an academic center by 3 different surgeons. PATIENTS: We evaluated all of the consecutive patients who underwent a robot-assisted laparoscopic rectopexy between June 2002 and August 2010. INTERVENTION: Rectopexy was performed with 2 anterolateral meshes or with 1 ventral mesh, and in 9 patients a sigmoidectomy was associated with rectopexy. MAIN OUTCOME MEASURES: The actuarial recurrence rate was evaluated using the Kaplan-Meier method. RESULTS: During the study period, 77 patients underwent a robot-assisted laparoscopic rectopexy, and the mean age was 59.9 years (range, 23-90 y). Average operating time was 223 minutes (range, 100-390 min); the learning curve was completed after 18 patients were seen. Two patients died of causes unrelated to surgery at 5 and 24 months. There were 5 conversions (6%) to open procedure. Overall morbidity was low and concerned only 8 patients (10.4%). Mean follow-up time was 52.5 months (range, 12-115 mo). Recurrences have been observed in 9 patients (12.8%). Preoperatively, 24 (34%) of the patients had constipation. Postoperatively, constipation disappeared for 12 (50%) of 24 and constipation appeared for 11 (24%) of 46 patients. Fecal incontinence decreased after surgery from Wexner score 10.5 to 5.1 of 20. LIMITATIONS: There was a lack of standardization of the surgical procedure. The study was monocentric. Seven patients (9%) were lost to follow-up. CONCLUSIONS: Long-term results of robot-assisted laparoscopic rectopexy are satisfying. Further studies comparing robot-assisted and conventional laparoscopy, including cost-effectiveness, are needed.

The virtual reality simulator dV-Trainer(®) is a valid assessment tool for robotic surgical skills.

BACKGROUND: Exponential development of minimally invasive techniques, such as robotic-assisted devices, raises the question of how to assess robotic surgery skills. Early development of virtual simulators has provided efficient tools for laparoscopic skills certification based on objective scoring, high availability, and lower cost. However, similar evaluation is lacking for robotic training. The purpose of this study was to assess several criteria, such as reliability, face, content, construct, and concurrent validity of a new virtual robotic surgery simulator. METHODS: This prospective study was conducted from December 2009 to April 2010 using three simulators dV-Trainers(®) (MIMIC Technologies(®)) and one Da Vinci S(®) (Intuitive Surgical(®)). Seventy-five subjects, divided into five groups according to their initial surgical training, were evaluated based on five representative exercises of robotic specific skills: 3D perception, clutching, visual force feedback, EndoWrist(®) manipulation, and camera control. Analysis was extracted from (1) questionnaires (realism and interest), (2) automatically generated data from simulators, and (3) subjective scoring by two experts of depersonalized videos of similar exercises with robot. RESULTS: Face and content validity were generally considered high (77 %). Five levels of ability were clearly identified by the simulator (ANOVA; p = 0.0024). There was a strong correlation between automatic data from dV-Trainer and subjective evaluation with robot (r = 0.822). Reliability of scoring was high (r = 0.851). The most relevant criteria were time and economy of motion. The most relevant exercises were Pick and Place and Ring and Rail. CONCLUSIONS: The dV-Trainer(®) simulator proves to be a valid tool to assess basic skills of robotic surgery.