Meta-Analysis of the Impact of the Learning Curve in Robotic Rectal Cancer Surgery on Histopathologic Outcomes.

INTRODUCTION: Although the process of learning robotic surgery for rectal cancer is associated with a prolonged operating time and higher complication rates, its impact on histopathologic outcomes is unknown. The aim of this meta-analysis was to evaluate the impact of the learning curve in robotic surgery for rectal cancer on histopathologic outcomes. METHODS: The PubMed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL, and Web of Science databases were systematically searched. The inclusion criterion was any clinical study comparing the outcomes of robotic surgery for rectal cancer between different phases of the learning curve (LC) including competence (C). The primary endpoint was the circumferential resection margin (CRM) involvement rate defined as CRM ≤1 mm. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used for dichotomous variables. RESULTS: Ten studies including a total of 907 patients (521 LC and 386 C) were selected. Nine studies were found to have a low risk of bias, and one had a moderate risk of bias. The CRM involvement rate was 2.9% (13/441) for learning curve vs. 4.6% (13/284) for competence. This difference was not significant (OR (95%CI) = 0.70 (0.30, 1.60); p=0.39; I2=0%). CONCLUSION: A surgeon's learning curve seems to have no impact on CRM involvement rates compared to surgeon competence in robotic surgery for rectal cancer.

Evaluation of the Educational Environment of a Cadaver Course in Robotic Colorectal Surgery: A Cross-sectional Study.

BACKGROUND: The educational environment is a crucial metric of medical education that affects the course participants' motivation, achievement, happiness and success. The aim of this study was to evaluate the educational environment of a cadaver course in robotic colorectal surgery by comparing the perceptions of the participating residents to those of the participating surgeons. METHODS: This was a cross-sectional study carried out in 2017. Participants from the U.S. and Europe attended a course using eight fresh frozen cadaver torsos with no prior abdominal surgery. After course completion, participants anonymously completed 50-item Dundee Ready Educational Environment Measure (DREEM) questionnaires to evaluate five components of the educational environment: perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception. Internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient. Mean scores were compared using an independent samples t-test. RESULTS: Twenty of 24 participants completed the DREEM questionnaire, consisting of 9 residents and 11 surgeons (12 from the U.S., 8 from Europe). The internal consistency of the questionnaire was excellent (alpha=0.97). The mean total score was excellent for both residents and surgeons, and the difference between the groups was not significant (154.1±25.8 vs. 168.1±18.9, p=0.197). Perception of learning was significantly better among surgeons ("teaching highly thought of") than among residents ("a more positive perception") (40.5±3.6 vs. 35.7±5.6, p=0.04). CONCLUSIONS: This study suggests that the residents' perception of learning may have been negatively influenced by the participation of surgeons in the same cadaver station.

D3 Extended Mesenterectomy in Right Colectomy for Cancer: A Cadaver Simulation Model.

BACKGROUND: D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM. MATERIALS AND METHODS: Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon. RESULTS: Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264). CONCLUSIONS: Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.

A Retrospective Cohort Study to Determine Predictive Factors for Abdominal Wound Disruption Following Colorectal Surgery.

Abdominal wound disruption (AWD) is a postoperative complication that increases length of hospital stay, mortality, and cost. A retrospective cohort study was conducted to identify predictors of AWD, defined in the National Surgical Quality Improvement Program User Guide as a spontaneous reopening of a previously surgically closed (midline) wound that occurs within 30 days after index elective surgery in patients undergoing colorectal surgery. Data from the American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were searched, supplemented by institutional review board-approved chart review. Patients were identified using Current Procedural Terminology codes for open and laparoscopic abdominal colorectal procedures. Data were collected to predefined worksheets and entered into a statistical analysis program and included demographics; comorbidities; pre- and postoperative laboratory tests including white blood count, blood glucose, and albumin levels; date and type of procedure; wound classification; postoperative complication rate; type of access; time to disruption; surgical site infection (SSI); and use of the SSI intervention/prevention bundle. The Wilcoxon rank sum test was utilized to compare independent continuous variables between the groups, and Fisher's exact test was utilized to compare categorical variables. Variables with a P value <.2 at univariate logistic regression were included in multivariate logistic regression analysis. Time-to-event variables were compared using Cox regression analysis. Of the 690 patients included in the study, 16 (2.3%) developed an AWD. Mean age was 61.9 ± 15.3 years and 61.3 ± 15.0 years in AWD and non-AWD groups, respectively (P = .704). AWD occurred more frequently in men than women (75% vs. 50%; P = .040) and in patients who did compared to those who did not develop a deep incisional SSI (12.5% vs. 2%; P = .044). Preoperative albumin level was significantly lower in AWD (3.2 ± 0.8 vs. 3.8 ± 0.7; P = .006), as well as the proportion of post-bundle implementation (18.75% vs. 65.7%; P = .041). No significant differences were observed for any of the other variables examined. Per multivariate analysis, male gender (P = .05), absence of SSI bundle (P = .026), and hypoalbuminemia (P = .01) were independent predictors of AWD after elective colorectal resections. Time to AWD was significantly shorter in patients without SSI (P <.001). Results indicate implementation of the SSI bundle decreased AWD rates. Further prospective studies are needed to confirm these findings.