Patient-Reported Bowel, Urinary, and Sexual Outcomes After Laparoscopic-Assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial (ALaCart).

OBJECTIVE: The aim of this study was to compare patient-reported urinary, bowel, and sexual functioning of ALaCaRT Trial participants randomized to open or laparoscopic surgery for rectal cancer. SUMMARY BACKGROUND DATA: The primary endpoint, noninferiority of laparoscopic surgical resection adequacy, was not established. METHODS: Participants completed QLQ-CR29 at baseline, 3, and 12 months post-surgery. Additionally, women completed Rosen's Female Sexual Functioning Index (FSFI). Men completed the International Index of Erectile Function (IIEF) and QLQ-PR25. We compared the proportions of participants in each group who experienced moderate/severe symptoms/dysfunction at each time-point and compared mean difference scores from baseline to 12 months between groups. All analyses were intention-to-treat. Sexual functioning analyses included only the participants who expressed sexual interest at baseline. RESULTS: Baseline PRO compliance of 475 randomized participants was 88%. At 12 months, a lower proportion of open surgery participants experienced moderate-severe fecal incontinence and sore skin, compared to Laparoscopic participants, and a lower proportion of men randomized to open surgery experienced moderate-severe urinary symptoms. There were no differences at 3 months for bowel or urinary symptoms. Sexual functioning among sexually interested participants was similar between groups at 3 and 12 months; however, a lower proportion of women reported moderate to severe sexual dissatisfaction at 3 months in the open as compared to the laparoscopic group, (Rebecca.mercieca@sydney.edu.au., 95% CI 0.03-0.39). DISCUSSION: Despite the slightly lower proportions of open surgery participants self-reporting moderate-severe symptoms for 3 of 16 urinary/bowel domains, and lack of differences in sexual domains, it remains difficult to recommend one surgical approach over another for rectal resection.

Healthcare Costs of Laparoscopic versus Open Surgery for Rectal Cancer Patients in the First 12 Months: A Secondary Endpoint Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT).

BACKGROUND: Laparoscopic-assisted surgery for rectal cancer is widely used, however the healthcare costs are thought to be higher than for open resection. This secondary endpoint analysis of a randomized controlled trial aimed to evaluate total healthcare costs of laparoscopic-assisted surgery compared with open resection for rectal cancer over a 12-month period. METHODS: Patients in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were included in a prospective costing analysis. All healthcare use for the index surgery and hospital admission, readmissions, and follow-up care over 12 months were included. Unit costs were valued in Australian dollars (AUD$) using scheduled Medicare fees and hospital cost weights. The primary outcome was mean per patient cost. Non-parametric bootstrapping with 10,000 replications was undertaken for robustness checks. RESULTS: Data from 468 patients indicated that the laparoscopic-assisted surgical procedure incurred a mean cost of AUD$4542 (standard deviation [SD] AUD$1050)-AUD$521 higher than the open procedure mean cost of AUD$4021 (SD AUD$804) due to longer operative time and involvement of more costly equipment (95% confidence interval [CI] AUD$354-AUD$692). At 12 months, the average cost for the laparoscopic-assisted and open groups was AUD$43,288 (SD AUD$40,883) and AUD$45,384 (SD AUD$38,659), respectively, due to the shorter subsequent hospital stays. No overall significant cost difference between groups was found (95% CI -AUD$9358 to AUD$5003). One-way sensitivity analyses confirmed the robustness of the results. CONCLUSION: While initially higher, the costs of laparoscopic-assisted surgery for rectal cancer were similar to open resection at 12 months. Clinicians may choose a surgical approach based on clinical need. TRIAL REGISTRATION: The Australasian Gastro-Intestinal Trials Group (AGITG) was the legal sponsor and trial coordination was performed by the NHMRC Clinical Trials Centre. The trial was registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12609000663257).

Functional Outcome of Laparoscopic-Assisted Resection Versus Open Resection of Rectal Cancer: A Secondary Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial.

BACKGROUND: Low anterior resection syndrome has a significant impact on the quality of life in rectal cancer survivors. Previous studies comparing laparoscopic to open rectal resection have neglected bowel function outcomes. OBJECTIVE: This study aimed to assess whether there is a difference in the functional outcome between patients undergoing laparoscopic versus open resection for rectal adenocarcinoma. DESIGN: Cross-sectional prevalence of low anterior resection syndrome was assessed in a secondary analysis of the multicenter phase 3 randomized clinical trial, Australasian Laparoscopic Cancer of the Rectum Trial (ACTRN12609000663257). SETTING: There were 7 study subsites across New Zealand and Australia. PATIENTS: Participants were adults with rectal cancer who underwent anterior resection and had bowel continuity. MAIN OUTCOME MEASURES: Postoperative bowel function was evaluated using the validated low anterior resection syndrome score and Bowel Function Instrument. RESULTS: The Australasian Laparoscopic Cancer of the Rectum Trial randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. A total of 257 participants were eligible for, and invited to, participate in additional follow-up; 163 (63%) completed functional follow-up. Overall cross-sectional prevalence of major low anterior resection syndrome was 49% (minor low anterior resection syndrome 27%). There were no differences in median overall Bowel Function Instrument score nor low anterior resection syndrome score between participants undergoing laparoscopic versus open surgery (66 vs 67, p = 0.52; 31 vs 27, p = 0.24) at a median follow-up of 69 months. LIMITATIONS: The major limitations are a result of conducting a secondary analysis; the likelihood of an insufficient sample size to detect a difference in prevalence between the groups and the possibility of selection bias as a subset of the randomized population was analyzed. CONCLUSIONS: Bowel dysfunction affects a majority of rectal cancer patients for a significant time after the operation. In this secondary analysis of a randomized trial, surgical approach does not appear to influence the likelihood or severity of low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B794. RESULTADO FUNCIONAL DE LA RESECCIN ASISTIDA POR LAPAROSCOPIA VERSUS RESECCIN ABIERTA EN CNCER DE RECTO ANLISIS SECUNDARIO DEL ESTUDIO DE CNCER DE RECTO LAPAROSCPICO DE AUSTRALASIA: ANTECEDENTES:El síndrome de resección anterior baja tiene un impacto significativo en la calidad de vida de los supervivientes de cáncer de recto. Los estudios anteriores que compararon la resección rectal laparoscópica con la abierta no han presentado resultados de la función intestinal.OBJETIVO:Evaluar si existe una diferencia en el resultado funcional entre los pacientes sometidos a resección laparoscópica versus resección abierta por adenocarcinoma de recto.DISEÑO:La prevalencia transversal del síndrome de resección anterior baja se evaluó en un análisis secundario del ensayo clínico aleatorizado multicéntrico de fase 3, Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia (Australasian Laparoscopic Cancer of the Rectum Trial, ACTRN12609000663257).AJUSTE:Siete subsitios de estudio en Nueva Zelanda y Australia.PACIENTES:Los participantes eran adultos con cáncer de recto que se sometieron a resección anterior con anastomosis.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal posoperatoria se evaluó utilizando el previamente validado puntaje LARS y el Instrumento de Función Intestinal.RESULTADOS:El Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia asignó al azar a 475 pacientes con adenocarcinoma rectal T1-T3 a menos de 15 cm del borde anal. 257 participantes fueron elegibles e invitados a participar en un seguimiento adicional. 163 (63%) completaron el seguimiento funcional. La prevalencia transversal general de LARS mayor fue del 49% (LARS menor 27%). No hubo diferencias en la puntuación media general del Instrumento de Función Intestinal ni en la puntuación LARS entre los participantes sometidos a cirugía laparoscópica versus cirugía abierta (66 frente a 67, p = 0,52; 31 frente a 27, p = 0,24) en una mediana de seguimiento de 69 meses.LIMITACIONES:Las principales limitaciones son el resultado de realizar un análisis secundario; se analizó la probabilidad de un tamaño de muestra insuficiente para detectar una diferencia en la prevalencia entre los grupos y la posibilidad de sesgo de selección como un subconjunto de la población aleatorizada.CONCLUSIONES:La disfunción intestinal afecta a la mayoría de los pacientes con cáncer de recto durante un tiempo significativo después de la operación. En este análisis secundario de un ensayo aleatorizado, el abordaje quirúrgico no parece influir en la probabilidad o gravedad del síndrome de resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B794. (Traducción-Dr. Felipe Bellolio).

Aptitude and attitude: predictors of performance during and after basic laparoscopic skills training.

BACKGROUND: Manual dexterity and visual-spatial ability are considered key to the development of superior laparoscopic skills. Nevertheless, these abilities do not reliably explain all the variance found in the technical performance of surgical trainees. Consequently, we must look beyond these abilities to improve our understanding of laparoscopic skills and to better identify/develop surgical potential earlier on. PURPOSE: To assess the individual and collective impact of physical, cognitive, visual, and psychological variables on performance during and after basic simulation-based laparoscopic skills training. METHOD: Thirty-four medical students (laparoscopic novices) completed a proficiency-based laparoscopic skills training program (using either a 2D or 3D viewing mode). This was followed by one testing session, a follow-up testing session with new (yet similar) tasks, and a series of physical, cognitive, visual, and psychological measures. RESULTS: The statistical models that best predicted variance in training performance metrics included four variables: viewing mode (2D vs 3D), psychological flexibility, perceived task demands, and manual dexterity (bimanual). In subsequent testing, a model that included viewing mode and manual dexterity (assembly) best predicted performance on the pre-practiced tasks. However, for a highly novel, spatially complex laparoscopic task, performance was best predicted by a model that comprised viewing mode, visual-spatial ability, and perceived task demands. At follow-up, manual dexterity (assembly) alone was the best predictor of performance on new (yet similar) tasks. CONCLUSION: By focussing exclusively on physical/cognitive abilities, we may overlook other important predictors of surgical performance (e.g. psychological variables). The present findings suggest that laparoscopic performance may be more accurately explained through the combined effects of physical, cognitive, visual, and psychological variables. Further, the results suggest that the predictors may change with both task demands and the development of the trainee. This study highlights the key role of psychological skills in overcoming initial training challenges, with far-reaching implications for practice.

Clinical Evaluation of Intraoperative Near Misses in Laparoscopic Rectal Cancer Surgery.

OBJECTIVE: To investigate the frequency, nature, and severity of intraoperative adverse near miss events within advanced laparoscopic surgery and report any associated clinical impact. BACKGROUND: Despite implementation of surgical safety initiatives, the intraoperative period is poorly documented with evidence of underreporting. Near miss analyses are undertaken in high-risk industries but not in surgical practice. METHODS: Case video and data from 2 laparoscopic total mesorectal excision randomized controlled trials were analyzed (ALaCaRT ACTRN12609000663257, 2D3D ISRCTN59485808). Intraoperative adverse events were identified and categorized using the observational clinical human reliability analysis technique. The EAES classification was applied by 2 blinded assessors. EAES grade 1 events (nonconsequential error, no damage, or need for correction) were considered near misses. Associated clinical impact was assessed with early morbidity and histopathology outcomes. RESULTS: One hundred seventy-five cases contained 1113 error events. Six hundred ninety-eight (62.7%) were near misses (median 3, IQR 2-5, range 0-15) with excellent inter-rater and test-retest reliability (κ=0.86, 95% CI 0.83-0.89, P < 0.001 and κ=0.88, 95% CI 0.85-0.9, P < 0.001 respectively). Significantly more near misses were seen in patients who developed early complications (4 (3-6) vs. 3 (2-4), P < 0.001). Higher numbers of near misses were seen in patients with more numerous (P = 0.002) and more serious early complications (P = 0.003). Cases containing major intraoperative adverse events contained significantly more near misses (5 (3-7) vs. 3 (2-5), P < 0.001) with a major event observed for every 19.4 near misses. CONCLUSION: Intraoperative adverse events and near misses can be reliably and objectively captured in advanced laparoscopic surgery. Near misses are commonplace and closely associated with morbidity outcomes.

Laparoscopic skills training: the effects of viewing mode (2D vs. 3D) on skill acquisition and transfer.

BACKGROUND: Three-dimensional (3D) visual displays have been suggested to aid laparoscopic skills training by providing the depth cues not present in traditional two-dimensional (2D) displays. However, few studies have robustly investigated the impact of viewing mode (2D vs. 3D) on learning outcomes. PURPOSE: To examine how viewing mode (2D vs. 3D) impacts the acquisition and transferability of basic laparoscopic skills by comparing performance between transfer and control groups on a complete proficiency-based training program. METHOD: A counterbalanced between-subjects design was employed. Each participant was randomly allocated to one of four groups, comprising two transfer groups (trained in one viewing mode and tested in the alternate mode: the 2D → 3D and 3D → 2D groups) and two control groups (trained and tested in one viewing mode: the 2D → 2D and 3D → 3D groups). Participants completed proficiency-based training in six laparoscopic training tasks. Testing included two further repetitions of all tasks under test conditions. Objective performance measures included the total number of repetitions to reach proficiency, and total performance scores (i.e. time + error penalties across all repetitions) in training and testing. RESULTS: The groups trained in 3D demonstrated superior training performance (i.e. less time + errors) and took fewer repetitions to reach proficiency than the groups trained in 2D. The groups tested in 3D also demonstrated superior test performance compared to those tested in 2D. However, training mode did not yield significant test differences between the groups tested in 2D (i.e. 2D → 2D vs. 3D → 2D), or between the groups tested in 3D (i.e. 3D → 3D vs. 2D → 3D). CONCLUSION: Novices demonstrate superior performance in laparoscopic skills training using a 3D viewing mode compared to 2D. However, this does not necessarily translate to superior performance in subsequent testing or enhanced learning overall. Rather, test performance appears to be dictated by the viewing mode used during testing, not that of prior training.

Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial.

OBJECTIVE: The aim of the study was to determine the efficacy of laparoscopic rectal resection (Lap) versus open laparotomy and rectal resection (Open) for rectal cancer on locoregional recurrence (LRR) and disease-free survival (DFS) at 2 years. SUMMARY BACKGROUND DATA: Although a Lap approach to colon cancer surgery may offer similar oncological outcomes to Open with potentially less morbidity, this remains to be clearly established for the treatment of rectal cancer. METHODS: A randomized, multicenter noninferiority phase 3 trial of 475 patients with T1 to T3 rectal adenocarcinoma <15 cm from anal verge, given Lap or Open and followed for a minimum 2 years to assess LRR, DFS, and overall survival (OS). RESULTS: Secondary endpoint analyses included 450 patients (95%) without metastases at baseline (mean age 64; 34% women) who received Lap (n = 225) or Open (n = 225). Median follow-up was 3.2 years (range: 0.1-5.4 yrs). LRR cumulative incidence at 2 years: Lap 5.4%; Open 3.1% [difference, 2.3%; 95% confidence interval (CI), -1.5% to 6.1%; hazard ratio (HR) 1.7; 95% CI, 0.74-3.9]. DFS at 2 years: Lap 80%; Open 82% (difference, 2.0%; 95% CI, -9.3% to 5.4%; HR for recurrence or death, 1.17; 95% CI, 0.81-1.68; P = 0.41). After adjustment for baseline factors HR = 1.07 (95% CI, 0.7-1.6). OS at 2 years: Lap 94%; Open 93% (difference 0.9%; 95% CI, -3.6% to 5.4%). CONCLUSIONS: Laparoscopic surgery for rectal cancer did not differ significantly from open surgery in effects on 2-year recurrence or DFS and OS. Confidence intervals included potentially clinically important differences favoring open resection, so that the combination of primary and secondary study endpoints may not support laparoscopic resection of rectal cancer as a routine standard of care and further follow-up is required.

Transanal total mesorectal excision for rectal cancer: state of the art.

Achieving a high-quality total mesorectal excision (TME) resection specimen is a central tenet of curative rectal cancer management. However, operating at the caudal extremity of the pelvis is inherently challenging and a number of patient- and tumour-related factors may increase the risk of obtaining a poor TME specimen and positive resection margins. Transanal TME (TaTME) is an advanced surgical technique developed to overcome the limitations in pelvic exposure and instrumentation of transabdominal surgery. This up-to-date narrative review describes the evolution of TME surgery, the indications for TaTME, current published outcomes, its limitations and future developments.

Patient acceptance of the optical diagnosis and misdiagnosis of diminutive colorectal polyps.

BACKGROUND AND AIMS: Optical diagnosis allows for real-time endoscopic assessment of colorectal polyp histology and consists of the resect and discard and diagnose and leave paradigms. This survey assessed patient acceptance of optical diagnosis and their responses to a hypothetical doomsday scenario. METHODS: We conducted a 3-month cross-sectional survey of colonoscopy outpatients presenting to an Australian academic endoscopy center. RESULTS: A total of 981 patients completed the survey (76.0% response rate). The 60.8% of patients who supported resect and discard were more likely to be older men who co-supported diagnose and leave. Fewer patients (49.6%) supported diagnose and leave. A family history of missed cancer diagnosis (odds ratio [OR], 0.59; P = .003) was significantly associated with rejection of resect and discard, and a personal or family history of bowel cancer (OR, 0.7; P = .04) was significantly associated with rejection of diagnose and leave. In the hypothetical scenario of a cancerous polyp incorrectly left in situ leading to stage III disease, 208 (21.2%) patients would definitely ask for financial compensation, 584 (59.5%) were unsure, and 189 (19.3%) would definitely not seek compensation. The patient-proposed median value of compensation sought was $760,000 USD ($1,000,000 AUD; $1 AUD = $0.76 USD). Notably, 18.5% would be willing to give optical diagnosis another chance after this error. CONCLUSION: Patient support for optical diagnosis is limited, and those who are not supporters are more likely to seek financial compensation if errors occur.

Measurement Bias of Polyp Size at Colonoscopy.

BACKGROUND: The success of current and proposed strategies to reduce colorectal cancer (CRC) incidence and mortality rates are fundamentally based on measurement accuracy. OBJECTIVE: The aim of this study was to evaluate the densities of colorectal polyps individually measured at colonoscopy and whether measurement bias is a systemic phenomenon among colonoscopists. DESIGN: A population-wide, observational study. SETTING: All hospitals of the government-funded health system in Brisbane, Australia. PATIENTS: Our study investigated measurement bias at colonoscopy through systematic analysis of 8,591 individual polyp measurements recorded from 12,597 colonoscopies. All colonoscopies performed over a 12-month period between December 1, 2014, and November 30, 2015, were included. RESULTS: A total of 12,597 electronic colonoscopy reports were individually reviewed, hospital-by-hospital, and 8,591 individual size measurements from 18,276 detected polyps (47%) were obtained. LIMITATIONS: Our study is limited because the true size of unresected polyps was unknown. We chose not to compare pathologic and histologic sizes as resection specimens sent to pathologists are morphologically different and are measured differently to the pre-resection polyp images seen by endoscopists. CONCLUSIONS: Colonoscopists may be inaccurate in the measurement of polyp size and appear biased towards and against certain size measurements. These findings cast doubt over the validity of international post-polypectomy surveillance guidelines and the safety of optical diagnosis as a potential management paradigm for diminutive colorectal polyps. They also question the historical accuracy of polyp size data and risk estimates upon which these strategies were based.

Risk Factors for Recurrence After Laparoscopic Ventral Rectopexy.

BACKGROUND: Laparoscopic ventral rectopexy effectively treats posterior compartment prolapse. However, recurrence after laparoscopic ventral rectopexy is poorly understood. OBJECTIVE: This study aimed to evaluate factors contributing to recurrence after laparoscopic ventral rectopexy. DESIGN: A retrospective cohort analysis was performed of patients who underwent laparoscopic ventral rectopexy between June 2008 and June 2014. Patients presenting with full-thickness rectal prolapse were compared against the rest. Cox proportional hazards regression was used to determine predictors for recurrence. Operative findings of redo cases were evaluated. SETTINGS: This study was conducted under the supervision of a single pelvic floor surgeon. PATIENTS: A total of 231 patients with a median follow-up of 47 months were included. MAIN OUTCOME MEASURES: Clinicopathological risk factors and technical failures contributing to recurrence were analyzed. RESULTS: The overall recurrence rate was 11.7% (n = 27). Twenty-five recurrences occurred in patients with full-thickness rectal prolapse, of which 16 were full-thickness recurrences (14.2% (16/113)). Multivariate analyses showed predictors for recurrence to be prolonged pudendal nerve terminal motor latency (HR = 5.57 (95% CI, 1.13 - 27.42); p = 0.04) and the use of synthetic mesh as compared with biologic grafts (HR = 4.24 (95% CI, 1.27-14.20); p = 0.02). Age >70 years and poorer preoperative continence were also associated with recurrence on univariate analysis. Technical failures contributing to recurrence included mesh detachment from the sacral promontory and inadequate midrectal mesh fixation. LIMITATIONS: Modifications to the operative technique were made throughout the study period. A postoperative defecating proctogram was not routinely performed. CONCLUSIONS: Recurrence after laparoscopic ventral rectopexy is multifactorial, and risk factors are both clinical and technical. The use of biologic grafts was associated with lower recurrence as compared with synthetic mesh. Patients with full-thickness rectal prolapse who are elderly, have poorer baseline continence, and have prolonged pudendal nerve terminal motor latency are at increased risk of recurrence.

Indocyanine green fluorescence angiography (ICGFA) during laparoscopic and robotic colorectal surgery- a video vignette.

Anastomotic leaks are a dreaded complication of all colorectal surgery with the main factors contributing to it being tension on the anastomosis, intra-abdominal or systemic sepsis, distal obstruction, inadequate blood supply and improper surgical techniques. The leak rate of left-sided high colorectal resections can have a clinically significant leak rate from as low as 1-5% in high anterior resections to 7.9% in low anastomoses. This article is protected by copyright. All rights reserved.

The impact of crosstalk on three-dimensional laparoscopic performance and workload.

This is the first study to explore the effects of crosstalk from 3D laparoscopic displays on technical performance and workload. We studied crosstalk at magnitudes that may have been tolerated during laparoscopic surgery. Participants were 36 voluntary doctors. To minimize floor effects, participants completed their surgery rotations, and a laparoscopic suturing course for surgical trainees. We used a counterbalanced, within-subjects design in which participants were randomly assigned to complete laparoscopic tasks in one of six unique testing sequences. In a simulation laboratory, participants were randomly assigned to complete laparoscopic 'navigation in space' and suturing tasks in three viewing conditions: 2D, 3D without ghosting and 3D with ghosting. Participants calibrated their exposure to crosstalk as the maximum level of ghosting that they could tolerate without discomfort. The Randot® Stereotest was used to verify stereoacuity. The study performance metric was time to completion. The NASA TLX was used to measure workload. Normal threshold stereoacuity (40-20 second of arc) was verified in all participants. Comparing optimal 3D with 2D viewing conditions, mean performance times were 2.8 and 1.6 times faster in laparoscopic navigation in space and suturing tasks respectively (p< .001). Comparing optimal 3D with suboptimal 3D viewing conditions, mean performance times were 2.9 times faster in both tasks (p< .001). Mean workload in 2D was 1.5 and 1.3 times greater than in optimal 3D viewing, for navigation in space and suturing tasks respectively (p< .001). Mean workload associated with suboptimal 3D was 1.3 times greater than optimal 3D in both laparoscopic tasks (p< .001). There was no significant relationship between the magnitude of ghosting score, laparoscopic performance and workload. Our findings highlight the advantages of 3D displays when used optimally, and their shortcomings when used sub-optimally, on both laparoscopic performance and workload.

The Conflicting Evidence of Three-dimensional Displays in Laparoscopy: A Review of Systems Old and New.

OBJECTIVE: To describe studies evaluating 3 generations of three-dimensional (3D) displays over the course of 20 years. SUMMARY BACKGROUND DATA: Most previous studies have analyzed performance differences during 3D and two-dimensional (2D) laparoscopy without using appropriate controls that equated conditions in all respects except for 3D or 2D viewing. METHODS: Databases search consisted of MEDLINE and PubMed. The reference lists for all relevant articles were also reviewed for additional articles. The search strategy employed the use of keywords "3D," "Laparoscopic," "Laparoscopy," "Performance," "Education," "Learning," and "Surgery" in appropriate combinations. RESULTS: Our current understanding of the performance metrics between 3D and 2D laparoscopy is mostly from the research with flawed study designs. This review has been written in a qualitative style to explain in detail how prior research has underestimated the potential benefit of 3D displays and the improvements that must be made in future experiments comparing 3D and 2D displays to better determine any advantage of using one display or the other. CONCLUSIONS: Individual laparoscopic performance in 3D may be affected by a multitude of factors. It is crucial for studies to measure participant stereoscopic ability, control for system crosstalk, and use validated measures of performance.

The viewpoint-specific failure of modern 3D displays in laparoscopic surgery.

PURPOSE: Surgeons conventionally assume the optimal viewing position during 3D laparoscopic surgery and may not be aware of the potential hazards to team members positioned across different suboptimal viewing positions. The first aim of this study was to map the viewing positions within a standard operating theatre where individuals may experience visual ghosting (i.e. double vision images) from crosstalk. The second aim was to characterize the standard viewing positions adopted by instrument nurses and surgical assistants during laparoscopic pelvic surgery and report the associated levels of visual ghosting and discomfort. METHODS: In experiment 1, 15 participants viewed a laparoscopic 3D display from 176 different viewing positions around the screen. In experiment 2, 12 participants (randomly assigned to four clinically relevant viewing positions) viewed laparoscopic suturing in a simulation laboratory. In both experiments, we measured the intensity of visual ghosting. In experiment 2, participants also completed the Simulator Sickness Questionnaire. RESULTS: We mapped locations within the dimensions of a standard operating theatre at which visual ghosting may result during 3D laparoscopy. Head height relative to the bottom of the image and large horizontal eccentricities away from the surface normal were important contributors to high levels of visual ghosting. Conventional viewing positions adopted by instrument nurses yielded high levels of visual ghosting and severe discomfort. CONCLUSIONS: The conventional viewing positions adopted by surgical team members during laparoscopic pelvic operations are suboptimal for viewing 3D laparoscopic displays, and even short periods of viewing can yield high levels of discomfort.

A Multicenter Collaboration to Assess the Safety of Laparoscopic Ventral Rectopexy.

BACKGROUND: Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy. OBJECTIVE: This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts. DESIGN: This was a retrospective review. SETTINGS: The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy). PATIENTS: All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999-2013) at these centers were included in the study. MAIN OUTCOME MEASURES: The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity. RESULTS: A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients. LIMITATIONS: This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions. CONCLUSIONS: Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.

Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial.

IMPORTANCE: Laparoscopic procedures are generally thought to have better outcomes than open procedures. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection. OBJECTIVE: To determine whether laparoscopic resection is noninferior to open rectal cancer resection for adequacy of cancer clearance. DESIGN, SETTING, AND PARTICIPANTS: Randomized, noninferiority, phase 3 trial (Australasian Laparoscopic Cancer of the Rectum; ALaCaRT) conducted between March 2010 and November 2014. Twenty-six accredited surgeons from 24 sites in Australia and New Zealand randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. INTERVENTIONS: Open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238). MAIN OUTCOMES AND MEASURES: The primary end point was a composite of oncological factors indicating an adequate surgical resection, with a noninferiority boundary of Δ = -8%. Successful resection was defined as meeting all the following criteria: (1) complete total mesorectal excision, (2) a clear circumferential margin (≥1 mm), and (3) a clear distal resection margin (≥1 mm). Pathologists used standardized reporting and were blinded to the method of surgery. RESULTS: A successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and 208 patients (89%) in the open surgery group (risk difference of -7.0% [95% CI, -12.4% to ∞]; P = .38 for noninferiority). The circumferential resection margin was clear in 222 patients (93%) in the laparoscopic surgery group and in 228 patients (97%) in the open surgery group (risk difference of -3.7% [95% CI, -7.6% to 0.1%]; P = .06), the distal margin was clear in 236 patients (99%) in the laparoscopic surgery group and in 234 patients (99%) in the open surgery group (risk difference of -0.4% [95% CI, -1.8% to 1.0%]; P = .67), and total mesorectal excision was complete in 206 patients (87%) in the laparoscopic surgery group and 216 patients (92%) in the open surgery group (risk difference of -5.4% [95% CI, -10.9% to 0.2%]; P = .06). The conversion rate from laparoscopic to open surgery was 9%. CONCLUSIONS AND RELEVANCE: Among patients with T1-T3 rectal tumors, noninferiority of laparoscopic surgery compared with open surgery for successful resection was not established. Although the overall quality of surgery was high, these findings do not provide sufficient evidence for the routine use of laparoscopic surgery. Longer follow-up of recurrence and survival is currently being acquired. TRIAL REGISTRATION: anzctr.org Identifier: ACTRN12609000663257.

Case-matched series of a non-cross-linked biologic versus non-absorbable mesh in laparoscopic ventral rectopexy.

PURPOSE: Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh. METHODS: Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh. RESULTS: Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group. CONCLUSIONS: LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.