Educational implications for surgical telementoring: a current review with recommendations for future practice, policy, and research.

BACKGROUND: Surgical telementoring (ST) was introduced in the sixties, promoting videoconferencing to enhance surgical education across large distances. Widespread use of ST in the surgical community is lacking. Despite numerous surveys assessing ST, there remains a lack of high-level scientific evidence demonstrating its impact on mentorship and surgical education. Despite this, there is an ongoing paradigm shift involving remote presence technologies and their application to skill development and technique dissemination in the international surgical community. Factors facilitating this include improved access to ST technology, including ease of use and data transmission, and affordability. Several international research initiatives have commenced to strengthen the scientific foundation documenting the impact of ST in surgical education and performance. METHODS: International experts on ST were invited to the SAGES Project Six Summit in August 2015. Two experts in surgical education prepared relevant questions for discussion and organized the meeting (JP and HH). The questions were open-ended, and the discussion continued until no new item appeared. The transcripts of interviews were recorded by a secretary from SAGES. RESULTS: In this paper, we present a summary of the work performed by the SAGES Project 6 Education Working Group. We summarize the existing evidence regarding education in ST, identify and detail conceptual educational frameworks that may be used during ST, and present a structured framework for an educational curriculum in ST. CONCLUSIONS: The educational impact and optimal curricular organization of ST programs are largely unexplored. We outline the critical components of a structured ST curriculum, including prerequisites, teaching modalities, and key curricular components. We also detail research strategies critical to its continued evolution as an educational tool, including randomized controlled trials, establishment of a quality registry, qualitative research, learning analytics, and development of a standardized taxonomy.

Toward construct validity for a novel sensorized instrument-based minimally invasive surgery simulation system.

Minimally invasive surgical training is complicated due to the constraints imposed by the surgical environment. Sensorized laparoscopic instruments capable of sensing force in five degrees of freedom and position in six degrees of freedom were evaluated. Novice and expert laparoscopists performed the complex minimally invasive surgical task of suturing using the novel instruments. Their force and position profiles were compared. The novel minimally invasive surgical instrument proved to be construct valid and capable of detecting differences between novices and experts in a laparoscopic suturing task with respect to force and position. Further evaluation is mandated for a better understanding of the ability to predict performance based on force and position as well as the potential for new metrics in minimally invasive surgical education.

Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous ketorolac on length of hospital stay.

BACKGROUND: The objective of this study was to determine if intravenous ketorolac can reduce ileus following laparoscopic colorectal surgery, thus shortening hospital stay. METHODS: This was a prospective, randomized, double-blind, placebo-controlled, clinical trial of patients undergoing laparoscopic colorectal resection and receiving morphine patient controlled analgesia (PCA) and either intravenous ketorolac (group A) or placebo (group B), for 48 h after surgery. Daily assessments were made by a blinded assistant for level of pain control. Diet advancement and discharge were decided according to strictly defined criteria. RESULTS: From October 2002 to March 2005, 190 patients underwent laparoscopic colorectal surgery. Of this total, 84 patients were eligible for this study and 70 consented. Another 26 patients were excluded, leaving 22 patients in each group. Two patients who suffered anastomotic leaks in the early postoperative period were excluded from further analysis. Median length of stay for the entire study was 4.0 days, with significant correlation between milligrams of morphine consumed and time to first flatus (r = 0.422, p = 0.005), full diet (r = 0.522, p < 0.001), and discharge (r = 0.437, p = 0.004). There we no differences between groups in age, body mass index, or operating time. Patients in group A consumed less morphine (33 +/- 31 mg versus 63 +/- 41 mg, p = 0.011), and had less time to first flatus (median 2.0 days versus 3.0 days, p < 0.001) and full diet (median 2.5 days versus 3.0 days, p = 0.033). The reduction in length of stay was not significant (mean 3.6 days versus 4.5 days, median 4.0 days versus 4.0 days, p = 0.142). Pain control was superior in group A. Three patients required readmission for treatment of five anastomotic leaks (4 in group A versus 1 in group B, p = 0.15). Two of them underwent reoperation. CONCLUSIONS: Intravenous ketorolac was efficacious in improving pain control and reducing postoperative ileus when anastomotic leaks were excluded. This simple intervention shows promise in reducing hospital stay, although the outcome was not statistically significant. The high number of leaks is inconsistent with this group's experience and is of concern.

Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal.

BACKGROUND: Laparoscopic resection has become an accepted approach to gastrointestinal stromal tumors (GISTs), with acceptable early results published in the literature. Long-term recurrence rates, however, are still unclear, and the management of tumors in challenging locations requires exploration. METHODS: A retrospective analysis of all patients undergoing a laparoscopic resection of gastric GIST in our institution between November 1997 and July 2004 was performed. RESULTS: A total of 14 patients with 15 tumors were evaluated, 5 of which were located high on the lesser curve. All the patients had an attempted laparoscopic approach, with the following procedures performed: stapled wedge excision (n = 8), excision and manual sewing technique (n = 4), and distal gastrectomy (n = 1). Overall, there was a 15% (n = 2) conversion rate. Lesions found in the fundus and greater curvature areas were easily resected via simple stapled wedge excision. High lesser curve tumors were more difficult to manage and required a combination of methods for complete excision and preservation of the gastrointestinal junction including intraoperative gastroscopy, excision and manual sewing technique, and reconstruction over an esophageal bougie. There were no postoperative complications, and the length of hospital stay was 4.6 +/- 1.9 days. At a median follow-up period of 46.5 months (mean, 37.4 +/- 26 months), one patient experienced a recurrence (18 months postoperatively), with eventual disease-related death. CONCLUSION: The laparoscopic approach to gastric GIST tumors is safe and associated with acceptable short- and intermediate-term results. High lesser curve GISTs can be safely approached laparoscopically using various techniques to ensure an adequate resection margin without compromise of the GE junction.

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required.

BACKGROUND: Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed. METHODS: A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy. RESULTS: Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux). CONCLUSION: Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.

Optimizing technology for the management of colon and rectal diseases.

Surgery is one of the most dynamic sciences and the discipline of colorectal surgery continues to progress forward utilizing a combination of new technologies and innovative operative techniques to enhance patients care and improve outcomes.

Surgical management for rectal prolapse: an update.

Surgical management of rectal prolapse remains a challenge with the bredth of choices available and varies on the international, national, regional and locoregional level depending on expertise, comfort and perception of the available evidence. Long-standing opinions on approach of repair, abdominal vs. perineal, have been based on limited evidence and on anesethetic methods that are now relics of the past. Laparoscopic surgical repair and modern anesthethesia has made the abdominal approach more attractive even to the octagenerian with multiple comorbidities. Surgical management should still be individualized and prior to offering surgical correction of rectal prolapse one must understand each patient's syptoms, particularly incontinence and constipation, as well the effect rectal prolapse has on the patient's overall quality of life.

Achalasia developing years after surgery for reflux disease: case reports, laparoscopic treatment, and review of achalasia syndromes following antireflux surgery.

Two case reports demonstrate the paradoxical occurrence of achalasia many years after the successful surgical treatment of gastroesophageal reflux disease (GERD). These patients had remedial surgery laparoscopically. The three types of achalasia syndromes that can follow antireflux surgery are discussed. In type 1, primary achalasia is misdiagnosed as GERD and inappropriate antireflux surgery causes worsening dysphagia immediately after surgery without any symptom-free interval. In type 2, secondary iatrogenic achalasia is seen early after antireflux surgery and is characterized by the presence of stenosis and scar formation at the site of the fundic wrap. Although the motility studies resemble achalasia, the repair needs only to be taken down and refashioned when there is no response to balloon dilatation. In type 3, illustrated by the case reports, primary achalasia follows antireflux surgery after a significant symptom-free interval. There is complete absence of any stenosis or fibrosis of the esophagus and periesophageal tissues at remedial surgery. Moreover, surgical treatment of this condition needs to include esophageal myotomy.

Human antiglioma monoclonal antibodies from patients with astrocytic tumors.

The current management of malignant gliomas is unsatisfactory compared to that of other solid tumors; the expected median survival period is less than 1 year with the patient undergoing conventional surgery, radiotherapy, and chemotherapy treatment. Immunological reagents could be a useful adjunct. Human monoclonal antibodies derived from patients with astrocytic tumors might recognize subtle antigenic specificities that would differ from those recognized by xenogeneic (murine) systems. Five hybridomas, designated as BT27/1A2, BT27/2A3, BT32/A6, BT34/A5, and BT54/B8, were produced from the fusion of peripheral blood lymphocytes of four patients with astrocytic tumors to the human myeloma-like cell line TM-H2-SP2. This cell line has a 46, XX karyotype and is negative for hypoxanthine guanine phosphoribosyltransferase. All five human monoclonal antibodies produced 2.4 to 44 micrograms/ml of immunoglobulin M, had a similar but not identical pattern of reactivity against a panel of human tumor cell lines, and failed to react with normal human astrocytes. Labeling of four neuroectodermal tumor explant cultures by BT27/2A3 was demonstrated by flow cytometry. Karyotyping of three of the five hybridomas demonstrated that two were pseudodiploid (2-3n) and one hypodiploid (less than 2n). The monoclonality of the hybridomas was evaluated by Southern blot analysis of JH gene rearrangements, revealing two types of rearrangements for each hybridoma, both consistent with monoclonality. Preliminary antigen characterization indicated that at least four of the five human monoclonal antibodies were directed to cell-surface glycolipids.

Surgery for peptic strictures.

Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.

Operative treatment of malignancy.

The overall prognosis of patients afflicted with cancer of the esophagus is dismal and has not changed greatly over the last few decades. Improvements have largely been due to better perioperative care rather than new surgical techniques. There remain, about the optimal treatment of these patients, and these differences are summarized in this article. The principal elements required to make an appropriate surgical decision also are outlined. Until new markers for early detection and effective systematic therapy emerge, improvement is likely to occur only in subsets of patients referred early and treated in an environment that guarantees low operative mortality.

Laparoscopic splenectomy does the training of minimally invasive surgical fellows affect outcomes?

BACKGROUND: The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS). METHODS: Data were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows. RESULTS: Patient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p = 0.055), blood loss (214 vs 162 ml, p = 0.40), intraoperative complications (3 vs 2, p = 1.0), need for transfusion (2 vs 3, p = 1.0), conversions (1 vs 0, p = 1.0), length of hospital stay (3.3 vs 2.5 days, p = 0.13), and postoperative complications (1 vs 2, p = 1.0) were similar for the two groups. CONCLUSION: When performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.

Local recurrence and survival after laparoscopic mesorectal resection forrectal adenocarcinoma.

BACKGROUND: Laparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined. METHODS: A prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery. RESULTS: The median follow-up period was 31 months for patients with stages I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer. CONCLUSIONS: The survival and local recurrence rates for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP).

BACKGROUND: Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP). METHODS: Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients. RESULTS: Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70-335); and median blood loss was 100 cc (range, 20-1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1-12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission. CONCLUSIONS: Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.

Needlescopic surgery. A logical evolution from conventional laparoscopic surgery.

BACKGROUND: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. METHODS: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. RESULTS: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital

Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections.

BACKGROUND: To date, most large series of laparoscopic colorectal procedures have been descriptive reports that do not account for the potentially complex interaction of outcome predictors. The purpose of this study was to identify the preoperative factors that predict operative time, conversion to open surgery, and intraoperative and postoperative complications in laparoscopic colorectal surgery. METHODS: Multiple regression techniques were used to analyze 416 laparoscopic resections from a prospective database of laparoscopic colorectal procedures performed between April 1991 and April 1998. The preoperative factors considered were patient-specific (age, gender, weight) or disease-specific (diagnosis of cancer, Crohn's disease, diverticulitis, fistula). Surgical experience of < or =50 cases was also considered. Finally, all resections were represented by a combination of the following five procedure components: resections of the (a) hepatic flexure, (b) splenic flexure, (c) sigmoid, and (d) rectum, or (e) a perineal dissection. RESULTS: Patient weight, Crohn's disease, and each of the five individual procedure components incrementally lengthened operative time. Conversion to open surgery was influenced by the patient's weight, malignancy, and early experience of the surgeon. The risk of a postoperative complication was increased by the patient's age, resection of the perineum, and the presence of a fistula. No factors significantly influenced the risk of an intraoperative complication. CONCLUSIONS: Several preoperative factors that significantly affect outcomes in laparoscopic colorectal resections have been identified. Consideration of these factors may help in case selection and estimation of operating time; they should also be valuable when patients are informed of their risk of conversion and complications.

Needlescopic fundoplication.

BACKGROUND: Minimally invasive surgery continues to evolve, with an emphasis on developing new techniques and applying new technology to surgical procedures. The purpose of this study was to compare the short-term outcomes of needlescopic fundoplication with those of conventional laparoscopic fundoplication. METHODS: Between January 1999 and June 2000, 38 needlescopic fundoplications were performed, and the short-term outcomes for these patients were compared with those for a contemporary matched cohort of patients who had undergone a conventional laparoscopic fundoplication. RESULTS: There was a nonsignificant trend toward decreased operative time (143.4 to 127 min; p = 0.13), blood loss (54.3 to 48 ml; p = 0.30), narcotic requirements (29.5 to 19.5 morphine equivalents; p = 0.32), and length of hospital stay (1.78 to 1.49 days; p = 0.10) in the needlescopic group. There were no significant differences in intraoperative complications (2.6% vs 2.6%; p = 1.0). Two needlescopic cases were converted to laparoscopic cases because of obesity. Postoperatively, there were no significant differences in rates of early dysphagia (7.9% vs 7.9%), bloating (13.2% vs 5.3%; p = 0.43), or other complications (5.3% vs 5.3%) between the groups. There was a significant reduction in mean operative time for needlescopic fundoplication after the first four cases (166 +/- 44 vs 120 +/- 32 min; p = 0.03). CONCLUSIONS: Needlescopic fundoplication poses no disadvantage, and it offers the added cosmetic benefit of smaller incisions.

Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages?

BACKGROUND: Controversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls. METHODS: Perioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999. RESULTS: A total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n = 37) and open (n = 36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p = 0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p = 0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p = 0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p = 0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p = 0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p = 0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different. CONCLUSIONS: The results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.

Laparoscopic colorectal resection in octogenarians.

BACKGROUND: The number and proportion of patients aged ?80 years are increasing. These patients often require surgical care and suffer subsequent high rates of morbidity and mortality. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not well documented. METHODS: Octogenarians were identified from a large prospective database comprising 507 consecutive laparoscopic colorectal resections performed between 1991 and 1999 in a university setting. Preoperative comorbidity and surgical outcomes were analyzed. RESULTS: Sixty-two patients (30 men, 32 women) aged ?80 years were identified. Their mean age and weight were 85 years and 63 kg, respectively. Seven patients (11%) were converted to an open procedure. Four (6%) intraoperative complications occurred in four patients (one colon perforation, one small bowel perforation, one burned gallbladder serosa, and one missed lesion), necessitating two conversions. Twenty -four postoperative complications occurred in 19 patients (31%) (six ileus [10%], five wound infections [8%], five cardiac problems [8%], two urinary retentions [3%], two hemorrhages [3%], one abscess [2%], one pneumonia [2%], and two other [3%]). Intraoperative complications did not increase postoperative morbidity. Three patients (5%) died within 30 days of surgery. When the procedure was completed laparoscopically, the overall median postoperative hospital stay was 10.0 days; occurrence of a postoperative complication increased the median length of stay to 15.0 days. CONCLUSIONS: These results are superior to published historical controls involving open colorectal resection in octogenarians. Overall mortality, lung, and urinary tract complications were decreased, and there were no reoperations for small bowel obstruction. Laparoscopic colorectal resection is technically feasible and can be done safely in elderly patients. Results require randomization against those for open surgery to elucida te the real advantages of this technique.