Edward D. Auyang

Human NOTES cholecystectomy: transgastric hybrid technique.

BackgroundNatural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation Ko and Kalloo (Chin J Dig Dis 7:67–70, 2006); Wagh et al. (Clin Gastroenterol Hepatol 3(9):892–896, 2005); ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery (Gastrointest Endosc 63(2):199–203, 2006); and Pearl and Ponsky (J GI Surg 12:1293–1300, 2008). Cholecystectomy has been one of the most commonly performed NOTES procedures to date, with the majority being performed through the transvaginal approach Marescaux et al. (Arch Surg 142:823–826, 2007); Zorron et al. (Surg Endosc 22:542–547, 2008); and Ramos et al. (Endoscopy 40:572–575, 2008). Transgastric approaches for cholecystectomy have been shown to be technically feasible in animal models and in several unpublished human patients Sumiyama et al. (Gastrointest Endosc 65(7):1028–1034, 2007). This video demonstrates the technique by which we perform transgastric NOTES hybrid cholecystectomy in human patients.MethodPatients with symptomatic gallstone disease are enrolled under an IRB approved protocol. A diagnostic EGD is performed to confirm normal anatomy. Peritoneal access is gained using a needle-knife cautery and balloon dilation under laparoscopic visualization. Dissection of the critical view of safety is performed endoscopically. The cystic duct and artery are clipped laparoscopically and the gallbladder is dissected off of the liver. The gastrotomy is closed intralumenally and over-sewed laparoscopically. The gallbladder is extracted out the mouth.ResultsThis technique was used to successfully perform four NOTES hybrid transgastric cholecystectomies without operative complications.ConclusionsNOTES hybrid transgastric cholecystectomy can be performed safely in human patients. This procedure is still technically challenging given the current instrumentation that is available. In order to perform a pure NOTES transgastric cholecystectomy, a safe blind access method, improved retraction, endoscopic hemostatic clips, and reliable closure methods need to be developed.

SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).

The following Clinical Spotlight Review regarding the endoluminal treatment of gastroesophageal reflux disease is intended for physicians who manage and treat it. The review is meant to critically assess these techniques and the available evidence supporting their safety and efficacy. On the basis of the level of evidence, recommendations may or may not be given for their use in clinical practice.

The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial

PURPOSE Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. METHODS Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. RESULTS A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. CONCLUSIONS SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.

Natural orifice translumenal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy

BackgroundNatural orifice translumenal endoscopic surgery (NOTES), an emerging field in minimally invasive surgery, is driving the development of new technology and techniques. The NOTES approach has several proposed benefits including potentially decreased abdominal pain, wound infections, and hernia formation [1–4]. Cholecystectomy is one of the most commonly performed NOTES procedures to date [5–7]. To perform a safe cholecystectomy and reduce potential bile duct injuries, the cystic duct and artery must first be identified. Establishing this critical view of safety before ligation and division has been shown to reduce bile duct injuries associated with laparoscopic cholecystectomy [8]. This video shows that the critical view of safety can be attained with endoscopic dissection.MethodsIn the porcine model, transcolonic peritoneal access is gained using an endoscopic needleknife and balloon dilator. Once orientation is established, the gallbladder is retracted using percutaneous T-tags. The cystic duct and artery bundle are identified and then meticulously dissected using endoscopic graspers, hook cautery, biopsy forceps, and scissors. The individual cystic duct and artery are isolated and identified, establishing the critical view of safety. Endoscopic clip ligation and division are then performed, and the gallbladder is dissected free.ConclusionsDissection of the critical view of safety can be performed in a completely endoscopic fashion using appropriate instrumentation. By achieving this critical view, the incidence of biliary injury during NOTES should be minimal and similar to the incidence of biliary injury during laparoscopic surgery. While completing this procedure, we identified several remaining technical limitations and deficiencies. Endoscopic retraction of tissue still is challenging with currently available instrumentation. Hemostatic endoscopic clips are not currently available for cystic artery and duct ligation. With the development of such instruments, cholecystectomy and other NOTES procedures will become technically more feasible.

Administrative considerations when implementing ACS/APDS Skills Curriculum.

BACKGROUND With time and cost constraints, implementing an effective, yet efficient, skills curriculum poses significant challenges. Our purpose is to describe a successful curriculum administrative structure that promoted faculty buy-in and accountability, learner responsibility, and acceptable resource usage. METHODS A total of 14 American College of Surgery (ACS) modules were included in the postgraduate year 1 curriculum. Before arrival, 2 modules were sent to newly matched residents. Remaining modules were administered over a 4-month period, with integrated, independent practice opportunities, as well as 4 mentored and 1 peer practice sessions. A total of 2 verifications of proficiency (VOP) progress exams and 1 final comprehensive VOP were administered. To promote faculty ownership, 1 faculty member was asked to lead each module. Module leaders attended an orientation and development session, and created an instructional management plan. Each module was taught by the leader and 2 additional faculty coinstructors, and evaluated by residents. Equipment, resource costs, and man-hours were tracked. RESULTS Faculty buy-in was demonstrated by enthusiastic participation, with only 2 absences. Residents gave high ratings to all the modules (range, 4.22-4.89/5). Curriculum costs were approximately

Readiness of US General Surgery Residents for Independent Practice

21,500, reduced from potential costs of

NOTES: cadaveric rendezvous hybrid small bowel resection

187,000 if all simulators would have been purchased new. The estimated budget for year 2 is

How I Do It: Laparoscopic Paraesophageal Hernia Repair

17,000. CONCLUSION It is critical for new curricula to have resident and faculty buy-in, accountability for quality teaching and learning, and reasonable resource use. We provide suggestions for structuring a curriculum to ensure accomplishment of these important drivers.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment

Objective: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. Background: The American Board of Surgery has designated 132 procedures as being “Core” to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. Methods: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. Results: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at “Practice Ready” or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%–94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy (“Passive Help” or “Supervision Only”) increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence (“Supervision Only”) was 33.3%. Conclusions: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Chronic Abdominal Pain, Ascites, and Diarrhea: Seeing Red

BackgroundNatural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques [1–4]. Before NOTES gains widespread popularity, it must be proven to be a safe and efficacious technique [5]. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation.MethodsCurrently, most investigational NOTES procedures are performed using a single transgastric, transcolonic, or transvaginal access point to the abdomen. In order to provide greater range of motion and freedom of movement, a rendezvous procedure using simultaneous transgastric and transcolonic approaches was used to perform a small bowel resection. This video demonstrates a successful NOTES hybrid small bowel resection with the use of two laparoscopic ports in a cadaveric model. A powered stapling device attached to a flexible shaft is introduced transcolonically and facilitates division and re-anastamosis of the small bowel. A dual-channel operating endoscope introduced transgastrically allows for precise dissection and creation of enterotomies necessary for the small bowel resection.ConclusionsWhile technically challenging, NOTES hybrid small bowel resection can be accomplished with specially designed instrumentation utilizing the rendezvous technique. There are several technical limitations preventing this procedure from being completed in a pure NOTES fashion. A safe method of creating blind enterotomies will be needed to eliminate laparoscopic visualization of the enterotomy sites. Adequate endoscopic exposure and retraction of tissue is still difficult and currently requires percutaneous adjuncts. New closure devices will be needed for safe and reliable NOTES enterotomy closure. With the development of such instruments, this, as well as other NOTES procedures, will become more technically feasible.