Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study.

INTRODUCTION: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. METHODS: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. RESULTS: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). CONCLUSIONS: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

Prior Robotic Console Expertise May Improve Basic Skills at the New Hugo RAS Simulator: Results from a Cohort Trial and Implications for Skill Transference Across Platforms.

Background: Robot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator. Objective: This study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator. Design setting and participants: We present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons. Intervention: All participants underwent a hands-on "pick and place" exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded. Outcome measurements and statistical analysis: Metrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console). Results and limitations: All participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower (p < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34-45) compared with both naïve participants (61 s, IQR 53-71) and laparoscopists (93 s, IQR 53-162). The overall score of the exercise decreased with age (p = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups (p = 0.006). Neither gender (p = 0.7) nor videogame use (p = 0.9) correlated significantly with the metrics. Conclusions: This is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue. Patient summary: In the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform.

Impact of hands-on practice with HugoRAS and Versius System simulators on the attractiveness of robotic surgery among medical and nurse undergraduate students.

The scenario of robotic surgery is rapidly evolving with the introduction of new robotic systems. A structured learning program in robotic surgery during academic education is often lacking, especially for undergraduates; as a result, many students may be unaware of indications to robotic surgery and technological progress. The aim of the study is to evaluate the knowledge and interest toward robotic surgery of medical and nurse students, and to analyze how the attractiveness may change after a hand-on training course with new simulators of Hugo RAS and Versius System. We performed a cross-sectional study involving medical and nurse students recruited on a voluntary basis at ASST Santi Paolo and Carlo, Milan; participants were invited to join a hands-on practice simulation with the Hugo RAS and/or Versius Trainer Simulator. Before the hand-on exercise, students were asked to fulfill an online anonymous questionnaire addressing knowledge and interest toward robotic surgery. After a 2-h hands-on exercises at the Hugo RAS and/or at the Versius Trainer simulator (preceded by a brief lecture on robotic surgery and new systems), participants were asked to complete a second-round questionnaire to evaluate changes in attractiveness toward robotic surgery. Data were recorded in a database; after a descriptive analysis of the variables, median values were compared with the Mann-Whitney U test, frequencies with the Fisher's exact test and in the case of paired observations (before and after the simulation), the Mc Nemar test was used. Forty-one undergraduates agreed to participate. Twenty-three nursing students and 18 medical students were recruited. Some of them had a basic knowledge in robotic surgery and were able to figure out some surgical indications, given the presence of a robotic program already settled up at the institution. Before the hands-on course, 44.0% nurse students and 36.6% of medical students were interested in surgical disciplines and robotic surgery. After the simulation, all students (100%) reported a high level of interest in robotic surgery and some of them required for a dedicated internship (p < 0.001). The students provided also feedback on the perceived ease-of-use of the robotic simulators (on a scale 0-10); overall, the median score was 8, IQR [7-8], with no differences between nursing and medical students (p = 0.482). In conclusion, the study demonstrates a great interest toward robotic surgery as a part of medical and nurse education. A hands-on simulation further improved the interest of undergraduates from both backgrounds. The technological progress with the availability of new surgical systems will be the future challenge of training programs and should be considered at all levels of education.