Advanced training in laparoscopic abdominal surgery: A systematic review

Training and credentialing in laparoscopic surgery — the need of the day

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Open abdominal procedures are associated with high levels of postoperative surgical stress that can impede recovery of physiological functions. Trauma resulting from aggressive manipulation of organs, and especially the intestine, can increase postoperative complications and result in delay in normal recovery. In an attempt to minimize complications and overall duration of hospital stay, fast track strategies, called “early recovery after surgery” (ERAS) protocols, have been adopted. Laparoscopic surgery has recently been identified as a major component of rapid recovery. One of the key differences between the open and the laparoscopic approach is the use of pneumoperitoneum for organ exposure during laparoscopy. Prolonged increase in abdominal pressure in addition to patient positioning can have a profound effect on hemodynamic parameters such as central venous pressure (CVP), cardiac output and intracranial pressure. Modifications in fluid administration, the choice of anesthetic agent and the depth of neuromuscular blockade are indicated to accommodate to the conditions imposed by pneumoperitoneum. Postoperatively, laparoscopic surgery is usually associated with less aggressive analgesia management. Based on ERAS protocols, patients are encouraged to initiate early oral feeding and to resume physical activity as soon as possible after abdominal surgery. While laparoscopic abdominal surgery is associated with reduced needs for pain medication, there appear to be no significant differences in early enteral feeding and mobilization between laparoscopic procedures and open surgery. When all factors are taken into consideration, however, laparoscopic colorectal surgery is associated with significant reduction in the duration of the total hospital stay, and is therefore recommended whenever feasible.

Current surgical training: simultaneous training in open and laparoscopic surgery

Limited information exists comparing the post-operative complication rate of laparoscopic or open abdominal surgeries in children with sickle cell disease (SCD). The primary objective of this study was to compare the outcomes in children with SCD who required laparoscopic or open abdominal surgery for a cholecystectomy or splenectomy. We conducted a retrospective analysis of laparoscopic and open abdominal surgeries performed in children with SCD (ages 0-20 years) at two medical centers from 1984 to 2004. The primary outcome measures were the rates of post-operative pain and acute chest syndrome (ACS) episodes following laparoscopic or open abdominal surgery. The secondary outcome was length of hospital stay following surgery. We also examined the potential contribution of pre-operative (transfusion) and intra-operative factors (operating time, estimated blood loss, and end-operative temperature) to post-operative SCD-related complications. A total of 140 cases were identified, 98 laparoscopic and 42 open. Episodes of post-operative pain and ACS episodes were comparable between laparoscopic and open procedures (pain: 4% vs. 3%, P = 0.619; ACS: 5% vs. 5%, P = 0.933). Additionally, laparoscopic surgeries were associated with a significantly shorter hospital stay (2.9 vs. 5.4 days, 95% CI -3.7 to -1.4, P < 0.001). There was no difference in the number of hospital readmissions within 1 month of the surgery. For children with SCD who need a cholecystectomy or splenectomy, laparoscopy is the preferred strategy because of a shorter hospital stay with a similar complication rate compared to open surgeries.

BackgroundA decrease in core body temperature caused by heat distribution depends on the anesthetic agent used. The purpose of this study is to investigate the effects of sevoflurane and propofol on core temperature during laparoscopic major abdominal surgery requiring pneumoperitoneum of more than 90 min.MethodsFifty adult patients undergoing laparoscopic major abdominal surgery were randomly assigned to either a sevoflurane group (n = 25) or a propofol group (n = 25). In the sevoflurane group, anesthesia was induced with propofol 2 mg/kg, remifentanil 1.0 µg/kg, and maintained with 0.8-2.0 vol% sevoflurane and 0.1-0.2 µg/kg/min remifentanil. In the propofol group, anesthesia was induced with the effect-site concentration of propofol of 5.0 µg/ml and remifentanil 4 ng/ml, and maintained with the effect-site concentration of propofol of 2-3.5 µg/ml and remifentanil 3-5 ng/ml. Core body temperature was measured with an esophageal stethoscope with a temperature sensor after the start of the pneumoperitoneum (baseline) and at 15-min intervals until completion of surgery.ResultsDuring the study period, core temperature was comparable between the two groups. When compared with baseline values, core temperatures in both groups were significantly decreased 45 min after pneumoperitoneum.ConclusionsThis study demonstrated that in patients undergoing prolonged laparoscopic surgery, a decrease in core body temperature during sevoflurane-remifentanil anesthesia was not different than propofol-remifentanil anesthesia, and the incidence of hypothermia of the two groups did not differ.

Laparoscopic simulators : Are they useful!

BackgroundSupervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself.MethodsA prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes.ResultsFrom 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4–82.2) versus 81.9% (74.2–90.4) and 70.0% (60.8–80.6) versus 73.6% (64.9–83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32–1.02, p = 0.057) and 0.87 (0.51–1.48, p = 0.61), respectively (univariate Cox proportional hazard model).ConclusionsStandardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.

The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery. An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed <100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C). In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [meanage: 56±17years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P=0.01), but not between group A and group C (P = 0.85) or between group B and group A(P=0.11). Converted patients were older (P<0.001), with lower rates of proctectomy (P=0.007), higher rates of anastomosis (P<0.001) and higher body mass index (BMI) (P<0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P=0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P<0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P<0.001) and time to solids (P<0.001). Converted patients experienced increased morbidity. Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.

Toward a Model of Human Information Processing for Decision-Making and Skill Acquisition in Laparoscopic Colorectal Surgery

The ACPGBI has been at the forefront in developing guidelines, position statements and national training programs related to both common, and complex, colorectal pathology. These initiatives often serve as a global reference in this challenging field. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) 2007 Colorectal Cancer Management Guidelines have been the basis for continuous evolution in the way these cancers are managed. The current update aims to clarify many recent developments on the multidisciplinary management of colorectal cancer and to provide links to relevant publications. The recommendations made within these guidelines have been graded according to the Oxford Centre for Evidence-based Medicine – levels of evidence (www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/). We hope that these guidelines will offer a framework for clinicians and MDT's to tailor treatments to suit individual patients. We also hope to direct future research and debate in a rapidly evolving field. A substantial part of the workload of colorectal units is to not only exclude diagnosis of cancer but to manage cancer of the colon, rectum and anal canal. Access to information through technology, and particularly the internet, has changed perceptions and expectations of cancer patients, their carers and clinicians. The general public and healthcare providers continue to shift focus towards cancer prevention and early diagnosis. At the other end of the spectrum, patients with locally advanced, recurrent or metastatic cancer are increasingly being considered for tailored multimodal therapy, based on molecular biology and pharmaceutical advances. In the UK, through the NCRI Colorectal Cancer Clinical Trials Group and numerous other research organizations, we are proud of our record of being at the forefront of designing and completing many internationally acclaimed oncological and surgical trials. These have been instrumental in shaping our current clinical practice. We must continue to build on this foundation by developing and recruiting into new trials to further improve treatment. Over the last few decades, multidisciplinary teams (MDTs) have evolved, and consolidated, in individual units to manage colorectal cancer. At the MDT meeting, the clinical nurse specialist, with the attending surgeon, are best positioned to act as the patients’ advocates and ensure crucial decisions are made with a first-hand knowledge of the patient and their wishes. It is pertinent that MDT recommendations are based on the available information and recommendations may, or may not be appropriate, or acceptable to the individual patient. Clinicians should support patients requesting second opinions and guide them with appropriate pathways. Current MDTs should look to extend their role in training junior surgeons, radiologists, histopathologists and oncologists, and mentoring new members of the core team. Personal-audits and regular feedback between core members should be an integral part of the development of the MDT. Ongoing sub-specialization has encouraged development of specialist MDTs in a number of areas including anal cancer, early rectal cancer, ‘beyond’-TME and recurrent pelvic cancers, and cytoreductive surgery. Teams treating colorectal disease need to recognize the spectrum of disease, diversity of treatments and develop care pathways to access specialist MDT's. Public awareness campaigns and the NHS Bowel Cancer Screening Program have impacted positively on the diagnosis of early stage disease, and polyp detection and clearance are likely to reduce colorectal cancer incidence. Introduction of Faecal Immunochemical Test and Bowel Scope Screening will further improve the stage at diagnosis of colon and rectal cancer. Bowel cancer screening has added to the challenge of treating polyp cancers and early rectal cancer; oncological adequacy of minimally invasive interventions (polypectomy and local excisions) vs morbidity and mortality risk of resection surgery. The ongoing SPECC (Significant Polyp Early Colorectal Cancer) Pelican/ACPGBI Program aims to stimulate discussion and training in these areas. Robust risk stratification tools to help MDTs and patients make informed decisions, especially in an older and frailer population, are needed. Clinical trials, such as the recently completed NCRI TREC-1 and the new NCRI STAR-TREC in early rectal cancer will add to this knowledge. The Laparoscopic Colorectal Surgery (LAPCO) program, which was a joint initiative between the ACPGBI and NHS England, delivered high quality accreditation training in laparoscopic surgery to NHS colorectal surgeons. This initiative, together with increasing public awareness of laparoscopic surgery, has resulted in a steady year-on-year increase in the proportion of cases treated by minimal access, whilst achieving good oncological outcomes in addition to the short-term early benefits, particularly in colon cancer but less so in rectal cancer. Introduction of ERAS on the background of minimally invasive surgery has improved short-term outcomes including length of stay. Optimal results have been reported using a combination of ERAS and minimal access techniques. The concepts from colorectal surgical ERAS programs have been adopted by other surgical fields and have benefited a wider group of patients. The Low Rectal Cancer Development (LOREC) program is another joint initiative between the ACPGBI and NHS England, providing training to MDTs on the overall management of cancers arising at, or below, the level of the insertion of the levator muscles, including the appropriate use of extralevator abdominoperineal excision (ELAPE). The longer-term oncological outcomes and the associated morbidity of this initiative are yet to be reported. High quality radiology and detailed histopathology reporting is crucial, as it underpins MDT decision making. This provides quality assurance to patients and clinicians on management decisions. Radiology and pathology provide valuable prognostic indicators in colon and rectal cancer, which helps to determine further management. Advances in imaging and use of biomarkers have initiated individualized treatment strategies to be developed in all stages of disease. We predict that these advances will expand exponentially in the next decade. The use of preoperative radiotherapy, with or without chemotherapy in addition to surgery in ‘operable’ rectal cancer reduces local recurrence rates, but much of the published evidence predates modern imaging, making it difficult to quantify the exact benefits. Together with ongoing improvements in surgical techniques, such as ELAPE for advanced low rectal cancer, and an increasing awareness of immediate and long-term toxicity, the risk-benefit of using radiotherapy in rectal cancer, either to downstage disease or to reduce local recurrence needs careful consideration on an individual basis. There remains significant variation in the use of radiotherapy nationally, but with further refinements in imaging and expansion of knowledge, this will allow more selective utilization. However the role of optimal surgery remains crucial. Further advances in the use of adjuvant chemotherapy, with the addition of new targeted agents have failed to materialize. The focus has shifted to earlier use of systemic therapy in the neoadjuvant setting for colon and rectal cancers, as well as reducing the duration and toxicity of adjuvant therapies. There is increasing worldwide interest in the potential for non-operative management of rectal cancers of all stages. Ongoing trials to improve pathological complete response rates (pCR) and translational studies to develop new predictive markers, together with high-quality observational trials such as the NCRI Deferral of Surgery, may allow for safe deferral and hopefully, complete avoidance of surgery in selected patients who have potentially achieved pCR after preoperative chemoradiotherapy (CRT). The National Bowel Cancer Audit (NBOCA) has evolved from being a voluntary audit when first launched in 2000, to currently being a quality assurance tool for individual surgeons and NHS Trusts. Although it has provided invaluable data to drive up the standards of care delivered nationally, there remain opportunities to further improve the quality of data collected. Through NBOCA, the publication of individual colorectal surgeons’ outcomes has empowered patients, by providing online information about volumes and outcomes of individual surgeons and NHS Trusts. Individual surgeon outcome reporting is contentious and unit data may be more meaningful and is the subject of ongoing discussion. Most importantly, treatment of colorectal cancer should take into account individual preferences, and be delivered with dignity, compassion and respect. Patients need to understand that the management of their cancer is individualized and complex. They should be given an explanation for the perceived delays in commencing treatment, such as the need for further investigations or MDT discussion. Response to treatment is often unpredictable, as are many of the acute and late toxicities. These uncertainties should be openly discussed and patients should be able to make informed choices about their care, in partnership with their healthcare professionals. These decisions should be subject to regular review at appropriate key points during treatment, to accommodate any changes in circumstances and to allow the patient the opportunity for further discussion or reconsideration. Healthcare professionals must not underestimate the psychological and social impact of a diagnosis of colorectal cancer on the individual as well as family, carers and supporters. There is wide variation in their reactions, their ability to cope and their recall of information received, which may be subject to strong emotions and anxiety. Communication and listening skills for such patients need to be exemplary as they form a vital part of the patient journey, from undergoing treatment, to recovery and eventual readjustment to life beyond hospital. These guidelines offer an updated framework for colorectal cancer clinicians and MDTs. They will continue to evolve and require updating in light of ongoing developments and emerging evidence. None of the authors have any conflicts to declare.

Objective To investigate the application value of the adhesive suspension of left lateral lobe of liver in transumbilical single-port laparoscopic left upper abdominal surgery. Methods The retrospective cross-sectional study was conducted. The clinical data of 112 patients who underwent single-port laparoscopic left upper abdominal surgery in the Shengjing Hospital of China Medical University between January 2010 and October 2016 were collected. Patients underwent single-port laparoscopic left upper abdominal surgery, and intraoperative surgical fields were exposed through adhesive suspension of left lateral lobe of liver. Observation indicators: (1) intraoperative situations: surgical completion, surgical procedures, time of liver adhesive suspension, total operation time and intraoperative liver adhesive suspension-related complications; (2) postoperative situations: pre- and post-operative alanine transaminase (ALT) and aspartate transaminase (AST) levels, hospital expenses and duration of hospital stay; (3) follow-up: number of patients with follow-up, follow-up time, complications during follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Repeated measurement data were analyzed using the repeated measures ANOVA. Results (1) Intraoperative situations: 112 patients underwent successfully single-port laparoscopic left upper abdominal surgery, without conversion to multi-port surgery or open surgery. Of 112 patients, 30, 23, 13, 11, 11, 10, 3, 3, 3, 3, 1 and 1 underwent radical resection of gastric cancer, partial gastrectomy, esophageal Heller myotomy + Dor fundo-plication, subtotal gastrectomy, resection of body and tail of pancreas, paraoesophageal hiatal hernia repair + fundoplication, total gastrectomy, splenectomy, splenectomy + devascularization, pancreatic tail resection, simple fundoplication and splenic artery aneurysm resection, respectively. Time of liver adhesive suspension and total operation time in 112 patients were respectively (1.4±0.4)minutes and (192.0±91.3) minutes. There was no hepatic laceration, hepatic subcapsular hematoma and other complications. (2) Postoperative situations: of 112 patients, preoperative ALT and AST levels of 6 patients were mildly elevated, postoperative ALT and AST levels in 2 of 6 patients returned to normal, that in 1 of 6 patients were elevated at day 1 postoperatively and returned to normal at day 3 postoperatively, and that in 2 of 6 patients remained mildly elevated at week 1 postoperatively; preoperative ALT and AST levels of 106 patients were normal, ALT and AST levels in 31 of 106 patients were elevated at day 1 postoperatively (that in 28 patients returned to normal within week 1 postoperatively, and that in 3 patients remained mildly elevated), and that in 75 of 106 patients returned to normal. ALT and AST levels of 112 patients were (16±11)U/L, (18±7)U/L before operation and (31±21)U/L, (34±26)U/L at day 1 postoperatively and (19±17)U/L, (19±12)U/L at week 1 postoperatively, respectively, with statistically significant differences in ALT and AST levels before operation and at day 1 postoperatively (F=36.353, 29.792, P 0.05). Hospital expenses, surgery-related expenses and duration of hospital stay were (45 231±20 440)yuan, (23 511±9 609)yuan and (6.0±1.9)days, respectively. (3) Follow-up: 112 patients were followed up for 1.0-3.0 months, with a median time of 1.6 months. During the follow-up, there were no obvious complications. Conclusion Adhesive suspension of left lateral lobe of liver is simple and safe, with satisfactory exposure effects, and it is suitable for the better operative field exposure in single-port laparoscopic left upper abdominal surgery. Key words: Gastric neoplasms; Left lateral lobe of liver; Suspension, adhesive; Left hypochondriac region; Laparoscopy, single-port

Objective To summarize robot-assisted laparoscopic abdominal surgery patient safety position management experience and nursing experience. Methods 60 cases of robotic abdominal surgery patients were retrospectively analyzed and summarized. Results The operations were successfully completed. There was no difficulty caused by improper posture. Conclusions Robot-assisted surgery placement position different from the conventional laparoscopic surgery, Appropriate surgical position can ensure smooth operation. Key words: Robotic laparoscopic surgery; Management position; Nursing care

Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years. A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest. Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge. Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.

IntroductionIn the last decade, we have seen the advance of laparoscopic surgery in urology. All laparoscopic procedures in our department are performed by staff members and are assisted by a single resident, ensuring resident training in laparoscopic surgery. The aim of this study is to evaluate the results of the Hospital La Paz training program for residents in the field of laparoscopic surgery.Material and methodsWe have done a retrospective review of LRP performed by the residents in our department. We also evaluated different variables. Descriptive statistical analysis was done and the results were compared with the descriptive analysis of the initial series of our department.ResultsWe reviewed 82 patients, with an average age of 61.6 years. Most cases were pT1c at diagnosis. Average surgical time was 288 minutes, with a transfusion rate of 9.7% and a intra and postoperative complication rates of 1.2% and 7.3%. The mean hospital stay was 3.3 days. Histological results of this series are: 76.8% of pT2 and 23.2% of pT3. The biochemical relapse rate is 15.8%. Global surgical margin rate is 20.7%. The global continence rate is 52.4%.ConclusionsThe outcomes of LRP performed by residents are similar to the ones reported in the initial series of our department. The fact that 84.6% of the residents formed in this period actually belong to different laparoscopic units supports the success of La Paz Hospital training model.