Retrospective evaluation of a hand-sewn side-to-side intestinal anastomosis technique in dogs and cats.

Background: Hand-sewn intestinal resection and anastomosis are commonly performed in veterinary medicine. The outcome of the hand-sewn side-to-side anastomosis (SSA) technique has never been described and compared to other techniques in dogs and cats. Aim: The study aims to describe the side-to-side hand-sewn anastomosis technique in small animals and to compare it with the end-to-end technique. Methods: A retrospective evaluation of the clinical records of dogs and cats that underwent enterectomy between 2000 and 2020 and were treated with side-to-side or end-to-end anastomosis (EEA) was performed. Results: Of the 52 dogs and 16 cats included in the study, 19 dogs and 6 cats received an SSA, and the remaining received an EEA. No intraoperative complication was reported. However, short-term complication rates were comparable, and mortality rates in the EEA group were higher. At the same time, stenosis was a frequent complication of SSA and was never reported following EEA. Conclusion: End-to-end technique remains the gold standard for hand-sewn intestinal anastomosis in small animals. However, SSA can be considered for selected cases with acceptable morbidity and mortality rates.

A Comparison of Outcomes of Proximal and Distal Anastomosis Sites of the Facial Artery in Head and Neck Reconstruction.

ABSTRACT: Recipient vessel selection in head and neck reconstruction is based on multiple factors, including defect size and location, patient history, and vessel location, diameter, and length. The authors present a comparison of proximal and distal anastomotic sites of the facial artery. A chart review of head and neck reconstructions using the facial artery as a recipient vessel over a 7-year period was conducted. The anastomosis site was identified as distal (at the inferior mandible border) or proximal (at the origin of the artery). The distal site was utilized for both defects of the midface/ scalp and of the mandible/neck, while the proximal site was exclusively used for mandible/neck defects. The following complications were included in the analysis: facial nerve injury, surgical site infection, thrombosis, flap congestion, flap loss, hardware failure, malunion/nonunion, osteomyelitis, sinus/fistula, hematoma, seroma, reoperation, and 90-day mortality. Fifty-four free tissue transfers were performed. The overall complication rate (including major and minor complications) was 53.7%. Anastomosis level did not have a significant impact on complication rate. In addition, there were no significant differences in complication rates for the distal anastomosis site when stratified by defect location. However, obese patients were more likely to have a complication than nonobese patients. This conclusion may reassure surgeons that factors related to anastomosis level, such as vessel diameter and proximity to the zone of injury, have less impact on outcomes than factors like obesity, which may inform preoperative planning, intraoperative decision-making, and postoperative monitoring.

Selection of Optimal Functional Lymphatic Vessel Cutoff Size in Supermicrosurgical Lymphaticovenous Anastomosis in Lower Extremity Lymphedema.

BACKGROUND: Functional lymphatic vessels are essential for supermicrosurgical lymphaticovenous anastomosis. Theoretically, the larger the lymphatic vessel, the better the flow. However, large lymphatic vessels are not readily available. Since the introduction of lymphaticovenous anastomosis, no guidelines have been set as to how small a lymphatic vessel is still worthwhile for anastomosis. METHODS: In this longitudinal cohort study, unilateral lower limb lymphedema patients who underwent lymphaticovenous anastomosis between March of 2016 and January of 2019 were included. Demographic data and intraoperative findings including the number and size of lymphatic vessels were recorded. The cutoff size was determined by receiver operating characteristic curve analysis, based on the functional properties of lymphatic vessels. Clinical correlation was made with post-lymphaticovenous anastomosis volume measured by magnetic resonance volumetry. RESULTS: A total of 141 consecutive patients (124 women and 17 men) with a median age of 60.0 years (range, 56.7 to 61.2 years) were included. The cutoff size for a functional lymphatic vessel was determined to be 0.50 mm (i.e., lymphatic vessel0.5) from a total of 1048 lymphatic vessels. Significant differences were found between the number of lymphatic vessels0.5 anastomosed (zero to one, two to three, and greater than over equal to four lymphatic vessels0.5), the median post-lymphaticovenous anastomosis volume reduction (in milliliters) (p < 0.001), and the median percentage volume reduction (p = 0.012). CONCLUSIONS: Lymphatic vessel0.5 can be a valuable reference for lymphaticovenous anastomosis. Post-lymphaticovenous anastomosis outcome can be enhanced with the use of lymphatic vessel0.5 for anastomoses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery.

AIM: The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. PATIENTS AND METHODS: We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. RESULTS: Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). CONCLUSION: AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory.

BACKGROUND: The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. METHODS: Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. RESULTS: Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. CONCLUSIONS: Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.

Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management.

PURPOSE: The urethro-vesical anastomosis represents one of the most challenging steps of robotic prostatectomy (RARP). To maximize postoperative management, we specifically designed our anastomosis quality score (AQS), based on the intraoperative characteristics of the urethra and bladder neck. METHODS: This is a prospective study, conducted from April 2019 to March 2020. All the patients were classified into three different AQS categories (low, intermediate, high) based on the quality of the anastomosis. The postoperative management was modulated accordingly. RESULTS: We enrolled 333 patients. According to AQS, no differences were recorded in intraoperative complications (p = 0.9). Median hospital stay and catheterization time were longer in AQS 1 group (p < 0.001). Additionally, the occurrence of postoperative complication was higher in AQS 1 category (p = 0.002) but, when focusing on the complications related to the quality of the anastomosis, no differences were found neither for acute urinary retention (p = 0.12) nor urine leakage (p = 0.11). Finally, concerning the continence recovery, no significant differences were found among the three groups for each time point. The highest potency recovery rate at one month of follow-up was recorded in AQS 3 category (p = 0. 03). CONCLUSION: The AQS proposed revealed to be a valid too to intraoperatively categorize patients who underwent RARP on the basis of the urethral and bladder neck features. The modulated postoperative management for each specific score category allowed to limit the occurrence of complications and to maximize the functional outcomes.

End-to-Side Microvascular Anastomosis on Rat Femoral Vessels Using Only 2-Throw Knot Interrupted Sututres - Evaluation of Feasibility and Patency Rates on Rat Femoral Vessels Model.

BACKGROUND: The use of a 3-throw knot for anastomosis by microvascular neurosurgeons is the usual standard. There is an inherent belief that the third throw adds extra security to the knot; however, the third throw can make the knot heavy and unbalanced and can exert undue extra pressure on the opposing walls of the small-caliber intracranial vessels. This study evaluated the feasibility and efficiency of 2-throw reef knot interrupted sutures for an end-to-side microvascular anastomosis. METHODS: A prospective observational study of end-to-side anastomosis using a femoral artery-to-vein model was performed in 30 Sprague-Dawley rats. All anastomoses were done using 2-throw reef knot interrupted sutures. Ten procedures each were done by the heel-first, toe-first, and classic 2-ends techniques. Individual parameters were recorded for analysis. The delayed patency was confirmed by reexploration after a mean duration of 19.82 ± 8.12 days. RESULTS: The overall patency rates were 100% in the immediate period and 96.43% (27 of 28) in the delayed period. The average clamping time, average suturing time, and the average time per suture were 65.48 ± 16.93 minutes, 40.94 ± 11.22 minutes, and 3.18 ± 1.10 minutes, respectively. Two rats died in the postoperative period. CONCLUSIONS: The end-to-side microvascular anastomosis with 2-throw reef knots is feasible, with excellent immediate and delayed patency rates.

Standard versus eversion-modified double-staple technique for low colorectal anastomoses after resection of rectal cancer.

PURPOSE: The double-staple technique, performed as either the standard procedure or after eversion of the rectal stump, is a well-established method of performing low colorectal anastomoses following the resection of rectal cancer. Eversion of the tumor-bearing ano-rectal stump was proposed to allow the linear stapler to be fired at a safe distance of clearance from the tumor. We conducted this study to compare the results of the standard versus the eversion-modified double-staple technique. METHODS: The subjects of this retrospective study were 753 consecutive patients who underwent low stapled colorectal anastomosis after resection of rectal cancer. The patients were divided into two groups according to the method of anastomosis used: Group A comprised 165 patients (22%) treated with the modified eversion technique and group B comprised 588 patients (78%) treated with the standard technique. The primary endpoints of the study were postoperative mortality, surgery-related morbidity, the number of sampled lymph nodes in the mesorectum, and late disease-related survival. RESULTS: Postoperative mortality was 1.2% in group A and 1.7% in group B (p = 0.66). Postoperative morbidity was 12% in group A and 11% in group B (p = 0.75). The mean number of sampled lymph nodes in the mesorectum was 23 (range 17-27) in group A and 24 (range 19-29) in group B (p = 0.06). The 5-year disease-related survival was 73% in group A and 74% in group B (p = 0.75). CONCLUSION: The standard and eversion-modified double-staple techniques yield comparable results.

Which is the Optimal Method of Reconstruction After Laparoscopic Right Hemicolectomy, the Intracorporeal or Extracorporeal Anastomosis Technique?

Introduction: The laparoscopic approach to right colectomy is gradually gaining a leading role in the surgical treatment of right colonic diseases. However, not all aspects of the procedure are standardized and the method of reconstruction of the digestive tract is still under debate. The present study critically evaluates the extracorporeal (EA) and intracorporeal (IA) techniques used for creation of the ileocolic anastomosis during a laparoscopic right colectomy. Material and Method: The EA and IA anastomotic techniques are described in detail. The peri operative data of a cohort of consecutive patients operated by our surgical team was retrospectively recorded and analyzed regarding type of anastomosis, the path for transition from EA to IA and the incidence of postoperative complications. Furthermore, an analysis of randomized clinical trials, reviews and meta-analyses that provided a comparative evaluation of EA versus IA was performed to provide a more in-depth integration of our own data into the literature. Results: EA was used at the beginning of our experience but was later replaced by IA which became the favorite anastomotic technique. There was no anastomotic fistula recorded in the EA or IA groups but in our cohort IA was unexpectedly associated with higher incidence of peritoneal drainage, prolonged ileus, surgical site infections, anastomotic bleeding and chyloperitoneum. However, IA allows better visualization of the ileal and colonic stumps, avoids twisting of the anastomosis, prevents extraction-related tearing of the mesocolon and reduces the risk of post operative hernia. Data from the literature also shows that IA is generally associated with earlier postoperative return of bowel function, less morbidity and less postoperative pain. Conclusions: Based on this study and the data currently present in the literature it can not be concluded that IA should be considered as the standard of care for laparoscopic right colectomy. The decision for an EA or IA anastomosis ultimately belongs to the surgeon and is influenced by his surgical skill and experience. The results of ongoing randomized controlled trials on large group of patients may bring more clarity on this issue in the future.

[Strengthening the quality control of coronary artery bypass grafting].

The quality control of coronary artery bypass grafting (CABG) is an important prerequisite to the graft patency and the long-term outcomes. The evaluation of target vessel is the basis, the choice of surgical types is the means, the high-quality acquisition of graft harvesting is the guarantee, and the anastomotic method and quality is the core. As the most commonly used quality control tool, intraoperative transit time flow measurement can effectively detect the coronary graft failure caused by anastomotic stenosis and guide to repair of the graft. However, some studies showed that the positive predictive value is low, and the evidence is insufficient for the relationship with the long-term patency rate of grafts. Intraoperative instantaneous flow measurement combined with high-resolution epicardial ultrasound can improve the quality, safety and effectiveness of CABG, which should be an important recommendation for CABG quality control. Once the shape of the grafts and anastomotic ports is abnormal and the blood flow is not satisfied, it needs to adjust or re-anastomose immediately. The quality control of CABG requires comprehensive judgment and individualized measures to ensure the safety and long-term outcome of patients.

The end game - A quantitative assessment tool for anastomosis in simulated microsurgery.

With the move towards simulation based microsurgical training and emphasis on the declining usage of animal models, there is a need for an objective method to evaluate microvascular anastomosis in a non-living, simulated microsurgical training environment. Our aim was to create a validated assessment tool to evaluate the intimal surface of the end product to measure skills acquisition. The intimal surface of 200 anastomoses from 23 candidates and 2 experts were assessed using ImageJ to measure 4 parameters: 1) distance between the distal insertion points, 2) distance between the proximal insertion points, 3) length of sutures placed, 4) number of axes. Using these parameters, a 9-component scoring system was produced based on the hypothesis of the ideal anastomosis having equidistance between the above parameters. The scoring system was devised based on population performance to give a maximum score of 100. The EPIA tool demonstrated its ability to differentiate between seniority from undergraduate to expert. Furthermore, predictive validity was shown by demonstrating skill acquisition between day 3 and 5 of the microsurgery course. The EPIA tool is a valid and feasible method to assess and provide feedback regarding the end product as an adjunct to current scoring systems in simulated microsurgery.

Achieving balance between resident autonomy and patient safety: Analysis of resident-led microvascular reconstruction outcomes at a microsurgical training center with an established microsurgical training pathway.

BACKGROUND: With advances in microsurgery, the published success rate of microsurgical reconstruction by experienced microsurgeons is greater than 95%. However, it is unknown whether the training residents can produce similar results. At our county hospital, residents perform and lead all aspects of microsurgical reconstruction, from raising the flap to performing microanastomoses. In this study, we retrospectively reviewed the outcomes of 156 consecutive microsurgical cases to determine the efficacy and safety of resident-led reconstructions at the county hospital. METHODS: We performed a retrospective review of patients who underwent microsurgical reconstruction at the county hospital from 2016 to 2018. Demographic, surgical procedure, flap characteristics, resident levels, and complication data were collected. RESULTS: Of the 156 free tissue flaps performed, the most commonly performed reconstruction was for the breast (62.8%), followed by lower extremity (15.9%), upper extremity (10.6%), head and neck (8.8%), and genitalia (1.8%). The average procedure time was 525.1 ±â€¯149.2 min, and mean ischemia time for each flap was 69.8 ±â€¯42.2 min. Venous anastomoses were performed by PGY3 (0.96%), PGY4 (27.9%), PGY5 (18.3%), and PGY6 (47.1%), while the arterial anastomoses were performed by PGY4 (16.4%), PGY5 (11.0%), and PGY6 (69.2%). The average number of anastomosis attempts was 1.3, with a range of 1 to 6. The overall flap success rate was 95.5% with a takeback rate of 7.1%. CONCLUSIONS: In conclusion, our analysis shows that resident-led reconstruction can achieve similar microsurgical success as that of published outcomes. We believe resident-led microsurgical reconstruction can be safely performed, with as-needed faculty assistance in high-risk and complicated cases, while allowing resident education and maturation of technical and decision-making skills.

Incorporation and validation of clinically relevant performance metrics of simulation (CRPMS) into a novel full-immersion simulation platform for nerve-sparing robot-assisted radical prostatectomy (NS-RARP) utilizing three-dimensional printing and hydrogel casting technology.

OBJECTIVES: To incorporate and validate clinically relevant performance metrics of simulation (CRPMS) into a hydrogel model for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). MATERIALS AND METHODS: Anatomically accurate models of the human pelvis, bladder, prostate, urethra, neurovascular bundle (NVB) and relevant adjacent structures were created from patient MRI by injecting polyvinyl alcohol (PVA) hydrogels into three-dimensionally printed injection molds. The following steps of NS-RARP were simulated: bladder neck dissection; seminal vesicle mobilization; NVB dissection; and urethrovesical anastomosis (UVA). Five experts (caseload >500) and nine novices (caseload <50) completed the simulation. Force applied to the NVB during the dissection was quantified by a novel tension wire sensor system fabricated into the NVB. Post-simulation margin status (assessed by induction of chemiluminescent reaction with fluorescent dye mixed into the prostate PVA) and UVA weathertightness (via a standard 180-mL leak test) were also assessed. Objective scoring, using Global Evaluative Assessment of Robotic Skills (GEARS) and Robotic Anastomosis Competency Evaluation (RACE), was performed by two blinded surgeons. GEARS scores were correlated with forces applied to the NVB, and RACE scores were correlated with UVA leak rates. RESULTS: The expert group achieved faster task-specific times for nerve-sparing (P = 0.007) and superior surgical margin results (P = 0.011). Nerve forces applied were significantly lower for the expert group with regard to maximum force (P = 0.011), average force (P = 0.011), peak frequency (P = 0.027) and total energy (P = 0.003). Higher force sensitivity (subcategory of GEARS score) and total GEARS score correlated with lower nerve forces (total energy in Joules) applied to NVB during the simulation with a correlation coefficient (r value) of -0.66 (P = 0.019) and -0.87 (P = 0.000), respectively. Both total and force sensitivity GEARS scores were significantly higher in the expert group compared to the novice group (P = 0.003). UVA leak rate highly correlated with total RACE score r value = -0.86 (P = 0.000). Mean RACE scores were also significantly different between novices and experts (P = 0.003). CONCLUSION: We present a realistic, feedback-driven, full-immersion simulation platform for the development and evaluation of surgical skills pertinent to NS-RARP. The correlation of validated objective metrics (GEARS and RACE) with our CRPMS suggests their application as a novel method for real-time assessment and feedback during robotic surgery training. Further work is required to assess the ability to predict live surgical outcomes.

Primary resection anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis.

Introduction: Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome. Methods: A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies. Results: A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38-0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14-1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20-2.78, p = 0.67). Conclusion: Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis.

BACKGROUND: Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. METHODS: A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. RESULTS: Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87). CONCLUSIONS: This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.

Ahead of the Curve: Tracking Progress in Novice Microsurgeons.

BACKGROUND: The purpose of this study was to evaluate learning curves for an existing microsurgical training model. We compared efficiency and amount of training needed to achieve proficiency between novice microsurgeons without operative experience versus those who had completed a surgical internship. METHODS: Ten novice microsurgeons anastomosed a silastic tube model. Time to perform each anastomosis, luminal diameter, and number of errors were recorded. RESULTS: First year residents improved up to a brief plateau at 10 repetitions, followed by continued improvement. Second year residents improved up to a plateau at 10 repetitions with no further improvement thereafter. There was no significant difference in luminal area or errors between groups. CONCLUSION: Residents with no operative experience can benefit from early exposure to microsurgical training. These interns continue to improve with additional repetitions while second year residents achieve proficiency with fewer repetitions.

The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard.

BACKGROUND: Several factors associated with interrupted and continuous suturing techniques affect the quality of bypass anastomosis. It is difficult to determine the impact of these factors during surgery. The primary objective of this study was to evaluate factors with the potential to influence the quality of bypass anastomosis using either interrupted or continuous suturing. A secondary objective was to evaluate the usefulness of a practical scale when comparing interrupted and continuous suturing techniques to improve bypass anastomosis. METHODS: Interrupted (n = 100) and continuous (n = 100) suturing techniques were used in 200 end-to-side bypasses to a depth of 3 cm and were assessed by 5 neurosurgeons. RESULTS: Vessel closing time (P < 0.001), stitch distribution (P < 0.001), intima-intima attachment (P < 0.001), and size of the orifice (P < 0.001) had a significant impact on the quality of the bypass regardless of the suturing technique used. The suturing technique used (interrupted or continuous) and positioning of the recipient vessel (vertical or horizontal) did not significantly influence the quality of anastomosis. Using multivariate analysis, the highest statistical significance with regard to bypass quality was attributed to the large size of the orifice and intimal attachment. CONCLUSIONS: There were advantages and disadvantages to both suturing techniques. The scale was a practical way to measure and improve performance.

[Application of double-pouch anastomosis in laparoscopic radical resection of rectal cancer assisted by small incision].

OBJECTIVE: To explore the feasibility, safety and the economical efficiency of double-pouch anastomosis in laparoscopic radical rectal cancer assisted by small incisions. METHODS: Clinical data of 224 patients undergoing gastrointestinal surgery at Taizhou People's Hospital of Jiangsu Province from January 2011 to December 2017 were retrospectively analyzed. Indusion criteria: patients were diagnosed as primary rectal adenocarcinoma by preoperative enteroscopy pathology, the distance of the tumor to anal margin was from 4 to 15 cm, and patients were treated with laparoscopic total mesorectal excision(TME) through small incision. Patients were divided into two groups according to different anastomosis method, double-pouch group(108 cases) and single-pouch group (116 cases). The surgical indexes, tumor safety indexes, short-term efficacy and economic indexes were compared between the two groups. RESULTS: There was no significant difference between two groups in baseline data, operative time, blood loss, number of lymph nodes dissection, average length of proximal and distal bowel, or incidence of urination and sexual dysfunction (all P>0.05). Compared with the single-pouch group, the double-pouch group presented lower anastomotic secondary bleeding rate [0.9%(1/108) vs. 6.0% (7/116), χ²=4.238, P=0.040], lower incidence of anastomotic leakage[1.9%(2/108) vs. 7.8%(9/116), χ²=4.179, P=0.041], lower incidence of anastomotic stricture [1.9% (2/108) vs. 8.6% (10/116), χ²=5.054, P=0.025], shorter hospital stay [(13.4±3.9) days vs. (15.9±9.8) days, t=2.524, P=0.013] and less average hospitalization costs [(34 000±7 000) yuan vs. (46 000±23 000) yuan, t=5.047,P<0.001]. There was no significant difference in local recurrence, distant metastasis or overall survival between the two groups during mean follow-up of 33 months (all P>0.05). CONCLUSION: Laparoscopic TME assisted by small incision with double-pouch anastomosis is a safe, feasible and economical method.

Preclinical Experience Using a New Robotic System Created for Microsurgery.

BACKGROUND: Robotic assistance in microsurgery could enhance human precision and dexterity to improve clinical outcomes. Because no robotic device has been designed primarily for microsurgery, the authors developed a dedicated microsurgical robotic system. This preclinical study investigates whether microsurgical anastomosis can be successfully completed on silicone vessels using a prototype of this new robotic system, and compares outcomes of robot-assisted versus conventional microsurgery. METHODS: Three participants at different levels of microsurgical training completed 10 anastomoses by hand and 10 anastomoses with robotic assistance. Four blinded, experienced microsurgeons evaluated the quality of the microsurgical skills using a modified version of the Structured Assessment of Microsurgical Skills. Time to perform the anastomosis and adverse events were recorded. RESULTS: The total time to perform the anastomoses with and without robotic assistance decreased to 35.1 minutes and 12.5 minutes, respectively, during the study. The overall performance and indicative skill of the Structured Assessment of Microsurgical Skills improved with the conventional method (from 2.8 to 3.6 and from 2.6 to 3.7, respectively) and the robot-assisted method (from 2.3 to 3.0 and from 2.3 to 3.1, respectively). CONCLUSIONS: It is feasible to complete anastomotic microsurgery on silicone vessels using the MicroSure robotic system. In comparison with the conventional method, time to perform the anastomosis was longer and quality of microsurgical skills was lower in the robot-assisted group. However, the robot-assisted performance showed steeper learning curves for both surgical time and domains of microsurgical skills. The encouraging results indicate further development of the system and (pre)clinical trials.

Comparative Prospective Study of Microvascular Anastomosis Training by Self-Learning or with Expert Instruction.

BACKGROUND: Young neurosurgeons have little opportunity to receive expert feedback while learning microvascular anastomosis. Our objective was to determine the importance of expert feedback. We compared students who studied anastomosis by self-learning with those who studied it with expert feedback. Our second objective was to determine the efficacy of intensive training by comparing the skills of the students with expert feedback with those of neurosurgeons. METHODS: Twenty-five medical students and 9 neurosurgeons participated. The students were provided with instructional Digital Video Disks (DVDs) and spent 2 weeks practicing gauze fiber microsuturing followed by 6 weeks practicing end-to-side anastomosis using silicone tube. The students assigned to the expert feedback group received weekly feedback through a video call, whereas those in the self-learning group did not. After training, the students completed a final practical examination that was recorded on DVD. The DVDs and procedural products were numbered and distributed to 2 blinded independent expert neurosurgeons for grading. The neurosurgeons completed a similar examination, and their performances were also recorded and compared with those of the medical students. RESULTS: Compared with the self-learning group, the expert feedback group showed significantly higher anastomosis scores (P = 0.0261) and a nonsignificant tendency toward slower anastomosis times (P = 0.4188). The expert feedback group also achieved significantly higher anastomosis scores than did the neurosurgeons (P = 0.0055). CONCLUSIONS: Expert feedback improves mastery of microvascular anastomosis. Intensive training with regular expert feedback enables medical students to achieve microvascular anastomosis skills better than those of neurosurgeons.