Danilo Miskovic

Standardization of laparoscopic total mesorectal excision for rectal cancer: a structured international expert consensus.

OBJECTIVEnTo establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME).nnnBACKGROUNDnLaparoscopic TME is a common surgical approach for the treatment of rectal cancer, but there is little agreement on technical details and standards.nnnMETHODSnSixty leading surgical experts from 5 different world regions with a median overall experience of 250 laparoscopic TME participated in this study. Four stages of mixed quantitative and qualitative consensus-finding methods were applied. (1) Semistructured expert interviews were independently analyzed by 2 assessors. (2) Consensus on the interview data was reached using reiterating questionnaires (Delphi method). (3) This was further refined in an interactive workshop. (4) Based on this meeting, a comprehensive text was drafted and final approval was sought by all experts.nnnFINDINGSnThree theme categories were identified in 9 detailed interviews (anatomical landmarks, description of tissue retraction, and operating strategies). Following 2 rounds of a 54-item questionnaire, 29 items achieved very high agreement (A* ≥90%), 14 with good agreement (≥80%), 13 with moderate agreement (≥50%), and 18 with little or no agreement (<50%). In the workshop, areas of agreement were consolidated and conclusions were sought for those with less agreement. The final document was approved after 2 further rounds of surveys by all respondents.nnnCONCLUSIONSnThis detailed and agreed technical description of laparoscopic TME may have implications on training, assessment, quality control, and future research.

Re-Validating the Observational Teamwork Assessment for Surgery Tool (OTAS-D): Cultural Adaptation, Refinement, and Psychometric Evaluation

AbstractBackgroundnThe nontechnical and team skills of surgical teams are critical for safety and efficiency in the operating room. Assessment of nontechnical and team skills can facilitate improvement by encouraging both self-reflection and team reflection, identifying training needs, and informing operating room (OR) team training approaches. The observational teamwork assessment for surgery (OTAS) tool is a well-validated and robust tool for capturing teamwork in the operating room. The aims of the present study were to systematically adapt and refine the OTAS for German-speaking OR staff and to test the adapted assessment tool (OTAS-D) for psychometric properties and metric equivalence.MethodsThe study was carried out in three stages: at stage 1, OTAS was translated into German. At stage 2, experienced German OR experts (surgeons, OR nurses, anesthetists) were interviewed. At stage 3, two blinded assessors observed 11 general surgical operations (general surgical and vascular procedures) and interrater reliability was tested for refined OTAS-D behavioral exemplars and scorings.ResultsThe German OR experts confirmed the applicability and content validity of the vast majority of translated behavioral exemplars. After their evaluation, 32 items were changed slightly, six were changed substantially, and one item was added. During observations, perfect and substantial interobserver agreement was found for 77 behavioral exemplars (67.1xa0% of the items, kappa coefficient >0.60). Rating at all OTAS behaviors showed acceptable levels of reliability (intraclass correlation coefficients >0.72).ConclusionsThe OTAS-D is a tool for valid and reliable assessment of nontechnical skills that contribute to safe and effective surgical performance in ORs staffed by German-speaking professionals. Furthermore, our study serves as an example for systematically adapting and customizing well-established observational tools across different healthcare environments.

Mental practice with interactive 3D visual aids enhances surgical performance

BackgroundEvidence suggests that Mental Practice (MP) could be used to finesse surgical skills. However, MP is cognitively demanding and may be dependent on the ability of individuals to produce mental images. In this study, we hypothesised that the provision of interactive 3D visual aids during MP could facilitate surgical skill performance.Methods20 surgical trainees were case-matched to one of three different preparation methods prior to performing a simulated Laparoscopic Cholecystectomy (LC). Two intervention groups underwent a 25-minute MP session; one with interactive 3D visual aids depicting the relevant surgical anatomy (3D-MP group, nu2009=u20095) and one without (MP-Only, nu2009=u20095). A control group (nu2009=u200910) watched a didactic video of a real LC. Scores relating to technical performance and safety were recorded by a surgical simulator.ResultsThe Control group took longer to complete the procedure relative to the 3D&MP condition (pu2009=u2009.002). The number of movements was also statistically different across groups (pu2009=u2009.001), with the 3D&MP group making fewer movements relative to controls (pu2009=u2009.001). Likewise, the control group moved further in comparison to the 3D&MP condition and the MP-Only condition (pu2009=u2009.004). No reliable differences were observed for safety metrics.ConclusionThese data provide evidence for the potential value of MP in improving performance. Furthermore, they suggest that 3D interactive visual aids during MP could potentially enhance performance, beyond the benefits of MP alone. These findings pave the way for future RCTs on surgical preparation and performance.

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training

BackgroundChanges in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training.MethodsSurgeons from various specialties were invited to attend a 1xa0day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons’ opinions of cadaveric simulation.ResultsAccording to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (pxa0=xa00.015). Thiel were found to be realistic (pxa0<xa00.001) to have reduced odour (pxa0=xa00.002) and be more cost-effective (pxa0=xa00.003). Ethical constraints were considered to be small.ConclusionThiel cadavers are suitable for training in most surgical specialties.

Anaesthetic and pharmacological techniques to decrease blood loss in liver surgery: a systematic review

There is increasing evidence that perioperative blood loss and blood transfusions are associated with poorer short‐ and long‐term outcomes in patients undergoing hepatectomy. The aim of this study was to systematically review the literature for non‐surgical measures to decrease intraoperative blood loss during liver surgery.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

BackgroundSurgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.MethodsSixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.ResultsThe participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 pxa0=xa00.64—NOM: 437 vs. 413 pxa0=xa00.88—PL cm: 1317 vs. 1059 pxa0=xa00.32—per: 0.5 vs. 0 pxa0=xa00.22—NCB: 0 vs. 0 pxa0=xa00.71—DVS: 0 vs. 0 pxa0=xa00.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 pxa0=xa00.02 η2xa0=xa00.32—Double cystic Artery (DA): 24.75 vs. 30.5 pxa0=xa00.03 η2xa0=xa00.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 pxa0=xa00.03 η2=0.34, DA: 0 vs. 1 pxa0= 0.02 η2 =xa00.22). in the cases with more challenging anatomies.ConclusionThese results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Achieving high quality standards in laparoscopic colon resection for cancer: A Delphi consensus-based position paper

AIMnTo investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on the opinion of experts leader in this field.nnnMETHODSnA systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training.nnnRESULTSnForty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7-35%. Using Delphi methodology, a laparoscopic colectomy was defined as a colon resection performed using key-hole surgery independently from the type of anastomosis. The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity).nnnCONCLUSIONnThe rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology.

Does monitor position influence visual-motor performance during minimally invasive surgery?

Background: In minimally invasive surgery (MIS), the natural relationship between hand and eye is disrupted, i.e. surgeons typically control tools inserted through the patient’s abdomen while viewing the workspace on a remote monitor, which can be located in a variety of positions. This separates the location of visual feedback from the area in which a motor action is executed. Previous studies suggest that the visual display should be placed directly ahead of the surgeon (i.e. to preserve visual-motor mapping). However, the extent of the impact of this rotation on surgical performance is unknown. Methods: Eighteen participants completed an aiming task on a tablet PC within a surgical box trainer using a laparoscopic tool in a controlled simulated environment. Visual feedback was presented on a remote monitor located at 0°, ±45° and ±90°, with order randomised using the Latin Square method. Results: Movements were significantly slower when the monitor was 90° relative to midline, but spatial accuracy was unaffected by monitor position. Interestingly, the effect of reduced speed in the 90° condition was transient, decreasing over time, suggesting rapid adaptation to the rotation. Conclusions: We conclude that the angle of the visual display in the context of MIS may require a surgeon to adapt to a changed mapping between visual inputs and motor outputs. While this adaptation occurs relatively quickly, it may interfere with skilled actions (e.g. intracorporeal suturing) in complex surgical procedures.

Impact of blood transfusion on outcomes following resection for colorectal liver metastases in the modern era

Evidence suggests that perioperative blood loss and blood transfusions are associated with poorer long‐term outcomes in patients undergoing other oncological surgery. The aim of this study was to determine the long‐term outcomes of patients requiring a blood transfusion post‐hepatectomy for colorectal liver metastases (CRLM).

Training Surgeons for Rectal Cancer Surgery: Clinical and Simulation

Rectal cancer surgery is complex, high stakes and is especially difficult to learn. This is due to the complex anatomy, rapid progression of technology and absolute necessity for optimal clinical and oncological outcomes. More often than not it is learnt within a traditional apprenticeship model, which is unsatisfactory. To overcome these difficulties educational principles must be used in conjunction with various training modalities. Cognitive training and virtual reality, animal and cadaveric simulation is necessary to climb the early part of the learning curve before operating on patients. Once in the operating room, interactive assistance, modular training and appropriate case selection ought to be combined to enhance the training experience whilst prioritizing patient safety. Competency based training progression has to be monitored and final competency demonstrated by assessment of operative videos and pathological specimens. Rectal cancer surgical training should occur in high volume centers of excellence with adequate volume, finances and appropriately trained faculty. This will result is a competency based, comprehensive, multimodal, multifocal and multi-site training program aimed at training high quality rectal surgeons whilst safeguarding patients.