Cognitive and motor skill competence are different: Results from a prospective randomized trial using virtual reality simulator and educational video in laparoscopic cholecystectomy.

BACKGROUND AND PURPOSE: Cognitive transfer represents an important issue in surgical education. It is essential for the acquisition of competence, such as decision making and error avoidance. This randomized study aims to compare the effectivity of cognitive transfer by observing the surgery versus using modern virtual reality simulators for learning a laparoscopic cholecystectomy. METHOD: This was a prospective, randomized, single centre study. 40 medical students from a university hospital, a tertiary care teaching institution, were enrolled. After a short introduction of laparoscopic cholecystectomy, they were randomized into two groups (video group and simulator group). In the video group, participants watched the step-by-step educational video twice. In the simulator group, participants underwent training using the virtual reality simulator, including tutorial procedural tasks of laparoscopic cholecystectomy as well as a complete cholecystectomy on the simulator. After the training, cognitive competence including decision making and error awareness was assessed using a questionnaire. RESULTS: In the most critical step of laparoscopic cholecystectomy, "Dissection in Calot's triangle", as well as in the aspect of planning next step, the video group was superior significantly (P = 0.038 and P = 0.04). No significant differences concerning the recognition of critical anatomical structures, choosing the necessary instruments as well as error awareness were found. CONCLUSIONS: Learning by watching a high-quality educational video is more effective in acquiring the cognitive competence to combine learned single tasks. Traditional learning means as watching educational videos and modern, sophisticated VRS should be deployed complementarily to establish cognitive and motor competencies separately.

Does caffeine consumption affect laparoscopic skills in a motion tracking analysis? A prospective, randomized, blinded crossover trial.

BACKGROUND: Coffee can increase vigilance and performance, especially during sleep deprivation. The hypothetical downside of caffeine in the surgical field is the potential interaction with the ergonomics of movement and the central nervous system. The objective of this trial was to investigate the influence of caffeine on laparoscopic performance. METHODS: Fifty laparoscopic novices participated in this prospective randomized, blinded crossover trial and were trained in a modified FLS curriculum until reaching a predefined proficiency. Subsequently, all participants performed four laparoscopic tasks twice, once after consumption of a placebo and once after a caffeinated (200 mg) beverage. Comparative analysis was performed between the cohorts. Primary endpoint analysis included task time, task errors, OSATS score and a performance analysis with an instrument motion analysis (IMA) system. RESULTS: Fifty participants completed the study. Sixty-eight percent of participants drank coffee daily. The time to completion for each task was comparable between the caffeine and placebo cohorts for PEG transfer (119 s vs 121 s; p = 0.73), precise cutting (157 s vs 163 s; p = 0.74), gallbladder resection (190 s vs 173 s; p = 0.6) and surgical knot (171 s vs 189 s; p = 0.68). The instrument motion analysis showed no significant differences between the caffeine and placebo groups in any parameters: instrument volume, path length, idle, velocity, acceleration, and instrument out of view. Additionally, OSATS scores did not differ between groups, regardless of task. Major errors occurred similarly in both groups, except for one error criteria during the circle cutting task, which occurred significantly more often in the caffeine group (34% vs. 16%, p < 0.05). CONCLUSION: The objective IMA and performance scores of laparoscopic skills revealed that caffeine consumption does not enhance or impair the overall laparoscopic performance of surgical novices. The occurrence of major errors is not conclusive but could be negatively influenced in part by caffeine intake.

Effect of Genre and amplitude of music during laparoscopic surgery.

PURPOSE: Music is often played in operating theaters. In the literature, the effects of music on surgeons are controversial. We aimed to investigate the effect of different music genres and amplitudes on laparoscopic performance. METHODS: Novice surgeons underwent a proficiency-based laparoscopic training curriculum. Participants were required to perform these tasks under three conditions: no music, with music in medium volume (45-50 dB) and in high volume (65-70 dB). Soft rock by the Beatles and hard rock by AC/DC were played. Task performance was evaluated by analyzing speed and accuracy. RESULTS: With soft rock in medium volume, participants were faster in peg transfer (60.3 vs. 56.7 s, P = 0.012) and more accurate in suture with intracorporeal knot (79.2 vs. 54.0, P = 0.011) compared to without music. The total score was improved (383.4 vs. 337.9, P = 0.0076) by enhancing accuracy (79.5 vs. 54.0, P = 0.011). This positive effect was lost if the soft rock was played in high volume. With hard rock in medium volume, participants were faster performing precision cutting (139.4 vs. 235.8, P = 0.0009) compared to without music. Both balloon preparation and precision cutting were performed more rapidly (227.3 vs. 181.4, P = 0.003, 139.4 vs. 114.0, P < 0.0001) and the accuracy was maintained. Hard rock in high volume also resulted in increased speed (366.7 vs. 295.5, P < 0.0001) compared to without music. Thereby, the total scores of participants were enhanced (516.5 vs. 437.1, P = 0.002). CONCLUSION: Our data reveal that the effect of music on laparoscopic performance might depend on the combination of music genre and amplitude. A generally well-accepted music genre in the right volume could improve the performance of novice surgeons during laparoscopic surgeries. TRIAL REGISTRATION: DRKS00026759, register date: 18.10.2021 (retrospectively registered).

Transferability of laparoscopic skills using the virtual reality simulator.

BACKGROUND: Skill transfer represents an important issue in surgical education, and is not well understood. The aim of this randomized study is to assess the transferability of surgical skills between two laparoscopic abdominal procedures using the virtual reality simulator in surgical novices. METHODS: From September 2016 to July 2017, 44 surgical novices were randomized into two groups and underwent a proficiency-based basic training consisting of five selected simulated laparoscopic tasks. In group 1, participants performed an appendectomy training on the virtual reality simulator until they reached a defined proficiency. They moved on to the tutorial procedural tasks of laparoscopic cholecystectomy. Participants in group 2 started with the tutorial procedural tasks of laparoscopic cholecystectomy directly. Finishing the training, participants of both groups were required to perform a complete cholecystectomy on the simulator. Time, safety and economy parameters were analysed. RESULTS: Significant differences in the demographic characteristics and previous computer games experience between the two groups were not noted. Both groups took similar time to complete the proficiency-based basic training. Participants in group 1 needed significantly less movements (388.6 ± 98.6 vs. 446.4 ± 81.6; P < 0.05) as well as shorter path length (810.2 ± 159.5 vs. 945.5 ± 187.8 cm; P < 0.05) to complete the cholecystectomy compared to group 2. Time and safety parameters did not differ significantly between both groups. CONCLUSION: The data demonstrate a positive transfer of motor skills between laparoscopic appendectomy and cholecystectomy on the virtual reality simulator; however, the transfer of cognitive skills is limited. Separate training curricula seem to be necessary for each procedure for trainees to practise task-specific cognitive skills effectively. Mentoring could help trainees to get a deeper understanding of the procedures, thereby increasing the chance for the transfer of acquired skills.

Impaired laparoscopic performance of novice surgeons due to phone call distraction: a single-centre, prospective study.

BACKGROUND: Distractions such as phone calls during laparoscopic surgery play an important role in many operating rooms. The aim of this single-centre, prospective study was to assess if laparoscopic performance is impaired by intraoperative phone calls in novice surgeons. METHODS: From October 2015 to June 2016, 30 novice surgeons (medical students) underwent a laparoscopic surgery training curriculum including two validated tasks (peg transfer, precision cutting) until achieving a defined level of proficiency. For testing, participants were required to perform these tasks under three conditions: no distraction (control) and two standardised distractions in terms of phone calls requiring response (mild and strong distraction). Task performance was evaluated by analysing time and accuracy of the tasks and response of the phone call. RESULTS: In peg transfer (easy task), mild distraction did not worsen the performance significantly, while strong distraction was linked to error and inefficiency with significantly deteriorated performance (P < 0.05). Precision cutting (difficult task) was not slowed down by mild distraction, but surgical and cognitive errors were significantly increased when participants were distracted (P < 0.05). Compared to mild distraction, participants reported a more severe subjective disturbance when they were diverted by strong distraction (P < 0.05). CONCLUSION: Our data reveals that phone call distractions result in impaired laparoscopic performance under certain circumstances. To ensure patient safety, phone calls should be avoided as far as possible in operating rooms.

A Study of Normothermic Hemoperfusion of the Porcine Pancreas and Kidney.

Normothermic machine perfusion has enormous potential to improve organ preservation and expand the organ donor pool. It is well established in other organs but not the pancreas, which has especially strict organ acceptance criteria. We established a model of normothermic hemoperfusion of the porcine pancreas with and without addition of the kidney as a dialysis organ. Four pancreases were harvested and perfused for 120 min with autologous whole blood at body temperature, two with parallel perfusion of the kidney and two without. The organs and perfusion circuit were evaluated for gross appearance, pH, histology and perfusion parameters. The organs maintained steadily increasing flow rate and perfusion pressure. Gross appearance of the organs was stable but appeared grossly ischemic toward the end of the perfusion period. Histology demonstrated necrosis centered in acinar tissue but islet cells were preserved. pH was significantly alkalotic toward the end of the perfusion, likely due to pancreatic tissue damage. Addition of the kidney did not result in significant improvement of the acid-base environment in this small series. In conclusion, normothermic perfusion of the pancreas is still in the experimental stages but holds great potential. Further studies to optimize perfusion parameters will significantly improve results. Parallel perfusion of the kidney may facilitate improvement in the acid-base environment.

Quality and outcomes of synchronous two-team Ivor-Lewis oesophagectomy: Revisiting a variant technique.

BACKGROUND AND OBJECTIVES: In 1975, a modification of popular two-stage Ivor-Lewis oesophagectomy was published with synchronous resection in chest and abdomen. As data on this technique are rare and inconsistent, we aimed to investigate safety, feasibility, and outcome of this approach. METHODS: Outcome of 201 patients undergoing synchronous oesophagectomy from 2000 to 2013 was analysed retrospectively. Two groups (early: 2000-2006; late: 2007-2013) were analysed to allow comparison of outcome over time. RESULTS: Patients in the later period had fewer respiratory comorbidities (P = 0.010), median blood loss decreased significantly over time while lymph node yield increased (P < 0.001). Overall complications occurred in 58.9 (early) versus 51.7% (late) of patients (P = 0.320), anastomotic leaks in 14.3 versus 6.7% (P = 0.112), respiratory complications in 48.2 versus 34.8% (P = 0.063). Thirty-day/90-day mortality was 2.7% versus 3.4, respectively, 8.1% versus 6.8% (P ≤ 0.793). Long-term survival was better in the later cohort (P = 0.004). CONCLUSIONS: Our data of 201 patients over a period of 14 years suggests that this technique is a quick, feasible, safe, and reasonable alternative to standard two-stage Ivor-Lewis oesophagectomy. Quality of this approach and ultimate outcomes have improved over time, with similar complication rates/outcomes to literature accepted standards for two-stage approach, especially in the later time period. J. Surg. Oncol. 2016;114:719-724. © 2016 Wiley Periodicals, Inc.

Acquisition and retention of laparoscopic skills is different comparing conventional laparoscopic and single-incision laparoscopic surgery: a single-centre, prospective randomized study.

BACKGROUND: Training in laparoscopic surgery is important not only to acquire and improve skills but also avoid the loss of acquired abilities. The aim of this single-centre, prospective randomized study was to assess skill acquisition of different laparoscopic techniques and identify the point in time when acquired skills deteriorate and training is needed to maintain these skills. METHODS: Sixty surgical novices underwent laparoscopic surgery (LS) and single-incision laparoscopic surgery (SILS) baseline training (BT) performing two validated tasks (peg transfer, precision cutting). The novices were randomized into three groups and skills retention testing (RT) followed after 8 (group A), 10 (group B) or 12 (group C) weeks accordingly. Task performance was measured in time with time penalties for insufficient task completion. RESULTS: 92 % of the participants completed the BT and managed to complete the task in the required time frame of proficiency. Univariate and multivariate analyses revealed that SILS (P < 0.0001) and precision cutting (P < 0.0001) were significantly more difficult. Males performed significantly better than females (P < 0.005). For LS, a deterioration of skills (comparison of BT vs RT) was not identified; however, for SILS a significant deterioration of skills (adjustment of BT and RT values) was demonstrated for all groups (A-C) (P < 0.05). DISCUSSION: Our data reveal that complex laparoscopic tasks (cutting) and techniques (SILS) are more difficult to learn and acquired skills more difficult to maintain. Acquired LS skills were maintained for the whole observation period of 12 weeks but SILS skills had begun to deteriorate at 8 weeks. These data show that maintenance of LS and SILS skills is divergent and training curricula need to take these specifics into account.

Procalcitonin--a Marker for Anastomotic Insufficiency after Pancreatoduodenectomy?

BACKGROUND: Anastomotic insufficiency after pancreatoduodenectomy (PD) represents a major complication in pancreatic surgery. Early detection and treatment of pancreatic fistulas (PF) are essential for the outcome of affected patients. Procalcitonin (PCT) is a biochemical marker which allows detection of bacterial infections. The aim of this study was to evaluate if PCT is suitable for early detection of PF after PD. METHODS: In this prospective study patients undergoing PD from 08/2010 to 09/2012 were included into three groups: (1) patients without complications (n = 19), (2) patients with postoperative infections (n = 14) and (3) PF (n = 7). Using a defined study protocol, clinical (e.g., vital signs, drain fluid, etc.) and laboratory parameters (full blood count, inflammatory markers) were assessed daily for the first ten postoperative days. RESULTS: 76 patients were assessed. 40 (52.6%) patients underwent PD and were included. CRP and PCT demonstrated an initial peak at the 1st to 3rd postoperative day with subsequent normalization. Patients with postoperative infections and PF showed a significant increase of PCT and CRP (p < 0.05) compared to patients without complications. Leucocyte counts demonstrated a variance in all three groups and clinical use for detection of complications was not evident. CONCLUSIONS: Patients with a postoperative complication revealed significantly increased levels of PCT and CRP without the expected normalization. PCT and/or CRP did not enable a distinction between patients with PF or postoperative infections. Thus, PCT does not seem to be suitable for detecting PF after PD and its use in the postoperative course after PD cannot be recommended.

Perioperative application of somatostatin analogs for pancreatic surgery-current status in Germany.

BACKGROUND: The most common major complication after pancreatic resection is the postoperative pancreatic fistula (POPF). Somatostatin analogs can reduce POPF, but the use of somatostatin analogs is still controversial. The aim of this study was to assess treatment algorithms for pancreatic surgery in Germany with a special focus on the application of somatostatin analogs. METHODS: A questionnaire evaluating the perioperative management-especially the use of somatostatin analogs-and postoperative complications after pancreatic surgery was developed and sent to 209 German hospitals performing >12 pancreatoduodenectomies per year (the requirement for certification as a pancreas center). Statistical analysis was carried out using SPSS 21. RESULTS: The final response rate was 77 % (160/209), 14.5 % of hospitals never, 37 % always, and 45 % occasionally apply somatostatin analogs after pancreatic surgery. A (standard) drug of choice was defined in 64 % of hospitals. When standard and occasional usage was analyzed, it appeared that hospitals favored somatostatin (69 %) > sandostatin (50 %) > pasireotide (5 %). A relation between the usage of the different somatostatin analogs and morbidity (POPF) or mortality (84 and 16 % of hospitals reported <5 and 5-10 %, respectively) was not seen. Eighty-seven percent of hospitals were interested in participating in future studies analyzing somatostatin use. CONCLUSION: This is the first national survey in Germany evaluating the perioperative application of somatostatin analogs for pancreatic surgery. Despite controversial results in the literature, the majority of German pancreas surgeons apply somatostatin analogs perioperatively. The ideal drug to reduce POPF is still unclear. This uncertainty has aroused significant interest and prompted surgeons to participate in future studies in order to elucidate this issue.

Prospective randomized assessment of acquisition and retention of SILS skills after simulation training.

BACKGROUND: Skills in single-incision laparoscopic surgery (SILS) are difficult to acquire. Simulation training leads to skill acquisition but circumstances about skill deterioration are unclear. The aim of this study was to evaluate skill acquisition and retention after single-incision laparoscopic simulation training. METHODS: From October 2013 to January 2014, 30 surgically naive participants underwent a SILS training curriculum and completed two validated tasks (peg transfer, precision cutting) with subsequent testing to assess acquisition of skills (baseline testing, BT). The participants were randomized into two groups and skill retention testing (RT) was measured after 4 weeks (group A) or 12 weeks (group B). Task completion was measured in time with penalties for inaccurate performance. RESULTS: A SILS training curriculum was established. 90 % of the participants completed the training successfully and reached the required levels of proficiency. Comparison of BT and RT revealed significantly better RT performances for peg transfer and precision cutting in group A (P < 0.05). These effects were not seen for RT in group B. Evaluating the RT performance of both groups, group A showed a non-significant trend for improved peg transfer and precision cutting compared to group B. CONCLUSION: A proficiency-based training curriculum for acquisition of basic SILS skills was successfully established in our department. The results of this study indicate that acquired SILS skills are well retained for a short period without training (4 weeks) but a longer non-training period (12 weeks) resulted in a significant loss of acquired skills. For enhancement of surgical skills, specialised SILS training curricula could be developed for novices and inexperienced surgeons; however, continuous training is essential to maintain these acquired skills.

Epigenetic regulation and role of metastasis suppressor genes in pancreatic ductal adenocarcinoma.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is distinguished by rapid dissemination. Thus, genetic and/or epigenetic deregulation of metastasis suppressor genes (MSG) is a likely event during early pancreatic carcinogenesis and a potential diagnostic marker for the disease. We investigated 9 known MSGs for their role in the dissemination of PDAC and examined their promoters for methylation and its use in PDAC detection. METHODS: MRNA expression of 9 MSGs was determined in 18 PDAC cell lines by quantitative RT-PCR and promoter methylation was analyzed by Methylation Specific PCR and validated by Bisulfite Sequencing PCR. These data were compared to the cell lines' in vivo metastatic and invasive potential that had been previously established. Statistical analysis was performed with SPSS 20 using 2-tailed Spearman's correlation with P < 0.05 being considered significant. RESULTS: Complete downregulation of MSG-mRNA expression in PDAC cell lines vs. normal pancreatic RNA occurred in only 1 of 9 investigated genes. 3 MSGs (CDH1, TIMP3 and KiSS-1) were significantly methylated. Methylation only correlated to loss of mRNA expression in CDH1 (P < 0.05). Bisulfite Sequencing PCR showed distinct methylation patterns, termed constant and variable methylation, which could distinguish methylation-regulated from non methylation-regulated genes. Higher MSG mRNA-expression did not correlate to less aggressive PDAC-phenotypes (P > 0.14). CONCLUSIONS: Genes with metastasis suppressing functions in other tumor entities did not show evidence of assuming the same role in PDAC. Inactivation of MSGs by promoter methylation was an infrequent event and unsuitable as a diagnostic marker of PDAC. A distinct methylation pattern was identified, that resulted in reduced mRNA expression in all cases. Thus, constant methylation patterns could predict regulatory significance of a promoter's methylation prior to expression analysis and hence present an additional tool during target gene selection.

Mimicry of human sepsis in a rat model--prospects and limitations.

BACKGROUND: Sepsis and systemic inflammatory response syndrome (SIRS) continue to represent critical conditions with persistently high mortality and continue to need experimental and clinical research. We developed a rat model of gram-positive and gram-negative SIRS/sepsis with in vivo visualization of the pulmonary microcirculation to evaluate the optimal dosage and application path for SIRS/sepsis-inducing agents. METHODS: Male Sprague-Dawley rats (n = 8 per group) were assigned to control, lipopolysaccharide (LPS), alphatoxin, or living Staphylococcus aureus (strain 68/50) groups. SIRS/sepsis was induced by intraperitoneal injection of the differing agents. The onset of SIRS was determined through human sepsis parameters and fluorescence video microscopy-based measurement of platelet and leukocyte velocity within the pulmonary vascular system (injection of 5 × 10(6) calcein AM-labeled nonactivated platelets; leukocytes labeled in vivo by rhodamine). RESULTS: The optimal dosage to induce SIRS was 30 mg/250 g body weight for LPS (bolus injection) and 60 µg/250 g body weight for alphatoxin (2 h continuous perfusion). Sepsis was not achieved by injection of living S. aureus. The onset of SIRS was seen after 2-5 h for LPS and after 2-4 h for alphatoxin after intraperitoneal administration with a significantly increased heart rate, breathing rate, and body temperature (P < 0.05) and significantly decreased cell velocity (P < 0.05). CONCLUSION: Our study represents an effective approach for a gram-negative (LPS) and gram-positive (alphatoxin) SIRS model to mimic human sepsis. Human sepsis-based criteria were used to define SIRS in our rats to achieve an optimal analogy for the human system. In our model, higher dosages were needed for SIRS induction than have been previously reported. The resulting, considerable heterogeneity of current SIRS-inducing models suggests that additional studies in this field are required to define standard procedures.

Blended learning in surgery using the Inmedea Simulator.

BACKGROUND: Recently, medical education in surgery has experienced several modifications. We have implemented a blended learning module in our teaching curriculum to evaluate its effectiveness, applicability, and acceptance in surgical education. METHODS: In this prospective study, the traditional face-to-face learning of our teaching curriculum for fourth-year medical students (n = 116) was augmented by the Inmedea Simulator, a web-based E-learning system, with six virtual patient cases. Student results were documented by the system and learning success was determined by comparing patient cases with comparable diseases (second and sixth case). The acceptance among the students was evaluated with a questionnaire. RESULTS: After using the Inmedea Simulator, correct diagnoses were found significantly (P < 0.05) more often, while an incomplete diagnostic was seen significantly (P < 0.05) less often. Significant overall improvement (P < 0.05) was seen in sixth case (62.3 ± 5.6 %) vs. second case (53.9 ± 5.6 %). The questionnaire revealed that our students enjoyed the surgical seminar (score 2.1 ± 1.5) and preferred blended learning (score 2.5 ± 1.2) to conventional teaching. CONCLUSION: The blended learning approach using the Inmedea Simulator was highly appreciated by our medical students and resulted in a significant learning success. Blended learning appears to be a suitable tool to complement traditional teaching in surgery.

Pancreatoduodenectomy--current status of surgical and perioperative techniques in Germany.

BACKGROUND: Pancreatoduodenectomy in Germany is performed by a broad range of hospitals. A diversity of operative techniques is employed as no guidelines exist for intra- and perioperative management. We carried out a national survey to determine the de facto German standards for pancreatoduodenectomy, assess quality assurance measures, and identify relevant issues for further investigation. METHODS: A questionnaire evaluating major outcome variables, case load, preferred surgical procedures, and perioperative management during pancreatoduodenectomy was developed and sent to 211 German hospitals performing >12 pancreatoduodenectomies per year (requirement for certification as a pancreas center). Statistical analysis was carried out using the Fisher Exact, Mann-Whitney U, and Spearman tests. RESULTS: The final response rate was 86 % (182/211). The preferred technique and de facto German standard for pancreatoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreatojejunostomy carried out via duct-to-mucosa anastomosis with interrupted sutures using PDS 4.0. The minority of German pancreas centers were certified (18-48 %). The certification rate increased with higher capacity levels and case load (P < 0.05); however, significant correlations between the fistula rate and hospital case load, hospital capacity level, or hospital certification status were not seen. CONCLUSION: This study revealed a distinct variety of management strategies for pancreatic surgery and available evidence-based data was not necessarily translated into clinical practice. The limited certification rate represented a shortcoming of quality assurance. The data emphasize the need for further trials to answer the questions whether hospital certifications and omission of drains improve outcome after pancreatoduodenectomy and for the establishment of guidelines for pancreatoduodenectomy.

Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence.

Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.

Does practice make perfect? Laparoscopic training mainly improves motion efficiency: a prospective trial.

Training improves skills in minimally invasive surgery. This study aimed to investigate the learning curves of complex motion parameters for both hands during a standardized training course using a novel measurement tool. An additional focus was placed on the parameters representing surgical safety and precision. Fifty-six laparoscopic novices participated in a training course on the basic skills of minimally invasive surgery based on a modified Fundamentals of Laparoscopic Surgery (FLS) curriculum. Before, twice during, and once after the practical lessons, all participants had to perform four laparoscopic tasks (peg transfer, precision cut, balloon resection, and laparoscopic suture and knot), which were recorded and analyzed using an instrument motion analysis system. Participants significantly improved the time per task for all four tasks (all p < 0.001). The individual instrument path length decreased significantly for the dominant and non-dominant hands in all four tasks. Similarly, both hands became significantly faster in all tasks, with the exception of the non-dominant hand in the precision cut task. In terms of relative idle time, only in the peg transfer task did both hands improve significantly, while in the precision cut task, only the dominant hand performed better. In contrast, the motion volume of both hands combined was reduced in only one task (precision cut, p = 0.01), whereas no significant improvement in the relative time of instruments being out of view was observed. FLS-based skills training increases motion efficiency primarily by increasing speed and reducing idle time and path length. Parameters relevant for surgical safety and precision (motion volume and relative time of instruments being out of view) are minimally affected by short-term training. Consequently, surgical training should also focus on safety and precision-related parameters, and assessment of these parameters should be incorporated into basic skill training accordingly.

Treatment options for postoperatively infected abdominal wall wounds healing by secondary intention.

PURPOSE: We present our current clinical approach for the treatment of postoperatively infected wounds of the abdominal wall healing by secondary intention that may help in the design of a randomized controlled trial to develop a standardized wound treatment pathway. METHODS: Patients with postoperatively infected abdominal wounds treated with either Advanced Wound Care (AWC) dressings or vacuum-assisted closure (VAC) therapy were enrolled in the study. Follow-up was carried out prospectively for wound healing and incidence of incisional hernia at the earliest 3 years after surgery. RESULTS: Sixty-two patients were included and wounds were initially treated antiseptically for 5.19 ± 2.91 days. Prior to VAC therapy, AWC dressings were applied for 8.75 ± 2.93 days to reduce reinfection. Greater wound size (>12 × 6 × 6cm) and extensive secretion (>200 ml/day) argued for the VAC system. Overall incidence of incisional hernia was 20.4%, with 18.4% occurring in AWC-treated patients and 27.3% in VAC-treated patients. Based on these results, a wound treatment pathway was established in our department. CONCLUSION: The established wound treatment pathway has helped to increase both workflow efficacy and outcome in the treatment of abdominal wounds. Wound size, amount of secretion, and status of infection were the parameters we used for the determination of appropriate treatment. The observational data gathered during the initiation of our pathway lay the basis for future randomized controlled trials that will determine the most appropriate treatment options in the setting of a standardized wound treatment pathway.

Decision Conflicts in Clinical Care during COVID-19: A Multi-Perspective Inquiry.

Background: The early COVID-19-pandemic was characterized by changes in decision making, decision-relevant value systems and the related perception of decisional uncertainties and conflicts resulting in decisional burden and stress. The vulnerability of clinical care professionals to these decisional dilemmas has not been characterized yet. Methods: A cross-sectional questionnaire study (540 patients, 322 physicians and 369 nurses in 11 institutions throughout Germany) was carried out. The inclusion criterion was active involvement in clinical treatment or decision making in oncology or psychiatry during the first year of COVID-19. The questionnaires covered five decision dimensions (conflicts and uncertainty, resources, risk perception, perception of consequences for clinical processes, and the perception of consequences for patients). Data analysis was performed using ANOVA, Pearson rank correlations, and the Chi²-test, and for inferential analysis, nominal logistic regression and tree classification were conducted. Results: Professionals reported changes in clinical management (27.5%) and a higher workload (29.2%), resulting in decisional uncertainty (19.2%) and decisional conflicts (22.7%), with significant differences between professional groups (p < 0.005), including anxiety, depression, loneliness and stress in professional subgroups (p < 0.001). Nominal regression analysis targeting "Decisional Uncertainty" provided a highly significant prediction model (LQ p < 0.001) containing eight variables, and the analysis for "Decisional Conflicts" included six items. The classification rates were 64.4% and 92.7%, respectively. Tree analysis confirmed three levels of determinants. Conclusions: Decisional uncertainty and conflicts during the COVID-19 pandemic were independent of the actual pandemic load. Vulnerable professional groups for the perception of a high number of decisional dilemmas were characterized by individual perception and the psychological framework. Coping and management strategies should target vulnerability, enable the handling of the individual perception of decisional dilemmas and ensure information availability and specific support for younger professionals.