Obtaining Adequate Surgical Margins in Breast-Conserving Therapy for Patients with Early-Stage Breast Cancer: Current Modalities and Future Directions

Inadequate surgical margins represent a high risk for adverse clinical outcome in breast-conserving therapy (BCT) for early-stage breast cancer. The majority of studies report positive resection margins in 20% to 40% of the patients who underwent BCT. This may result in an increased local recurrence (LR) rate or additional surgery and, consequently, adverse affects on cosmesis, psychological distress, and health costs. In the literature, various risk factors are reported to be associated with positive margin status after lumpectomy, which may allow the surgeon to distinguish those patients with a higher a priori risk for re-excision. However, most risk factors are related to tumor biology and patient characteristics, which cannot be modified as such. Therefore, efforts to reduce the number of positive margins should focus on optimizing the surgical procedure itself, because the surgeon lacks real-time intraoperative information on the presence of positive resection margins during breast-conserving surgery. This review presents the status of pre- and intraoperative modalities currently used in BCT. Furthermore, innovative intraoperative approaches, such as positron emission tomography, radioguided occult lesion localization, and near-infrared fluorescence optical imaging, are addressed, which have to prove their potential value in improving surgical outcome and reducing the need for re-excision in BCT

Game-based training improves the surgeon's situational awareness in the operation room: a randomized controlled trial

Equipment-related malfunctions directly relate to one-fourth of the adverse events in the surgical theater. A serious game trains residents to recognize and respond to equipment problems in minimally invasive surgery (MIS). These include disturbed vision, gas transport, electrocautery, and pathophysiological disturbances. This randomized controlled trial explores whether game-based training improves surgical residents' response to equipment-related problems during surgery. Thirty-one surgical residents with no previous experience in MIS took part in a standardized basic laparoscopy training course. Fifteen residents were randomly assigned to the game-enhanced curriculum (intervention) and sixteen were assigned to the regular curriculum (control). Participants performed a MIS task in a live anesthetized pig model, during which three standardized equipment malfunction scenarios occurred. Observers recorded the problems recognized and solved, time, and participants' technical performance. Twenty-four participants completed the post-test (n = 12 per group). The intervention group solved more problems than the control group (59 vs. 33%, p = 0.029). The intervention group also recognized a larger proportion of problems, although this parameter was non-significant (67 vs. 42%, p = 0.14). Random effects modeling showed a significant improved game performance per participant over time. Surgical residents, who play for only 1 h on a custom-made serious game, respond significantly better to equipment-related problems during surgery than residents trained by a standard training curriculum. These results imply that entertaining serious games can indeed be considered for use in official training for surgeons and other medical specialist

Prospective cohort study on surgeons' response to equipment failure in the laparoscopic environment

Equipment malfunction accounts for approximately one-fourth of surgical errors in the operating room. A serious game was developed to train surgeons in recognizing and responding to equipment failure in minimally invasive surgery (MIS) adequately. This study determined the baseline performance of surgeons, surgical residents, surgical novices, and MIS equipment technicians in solving MIS equipment failure. The serious game included 37 problem scenarios on the subjects lighting and imaging, insufflation and gas transport, electrosurgery, and pathophysiological disturbances. The scenarios were validated by laparoscopic surgeons and MIS equipment specialists. Forty-nine licensed surgeons, surgical residents, medical students, and MIS equipment specialists played four sessions on the serious game at a surgical convention. Scores on different outcome parameters were compared between groups of a different MIS experience. Laparoscopic equipment specialists solved significantly more MIS equipment-related problems than surgical novices, intermediates, and experts (68.9 vs. 51.0 %, 51.4, and 45.0 %, respectively, p = 0.01). Laparoscopic equipment specialists required significantly fewer steps to solve a problem accurately (median of 1.0 vs. 2.0 for the other groups). Most notably, experienced surgeons were unable to outperform novice and intermediate groups. Experienced surgeons took less time to solve the problems, but made more mistakes in doing so. Experienced surgeons did not outperform inexperienced surgeons in dealing with laparoscopic equipment failure. These results are worrying and need to be addressed by the surgical communit

A multicenter prospective cohort study on camera navigation training for key user groups in minimally invasive surgery

Untrained laparoscopic camera assistants in minimally invasive surgery (MIS) may cause suboptimal view of the operating field, thereby increasing risk for errors. Camera navigation is often performed by the least experienced member of the operating team, such as inexperienced surgical residents, operating room nurses, and medical students. The operating room nurses and medical students are currently not included as key user groups in structured laparoscopic training programs. A new virtual reality laparoscopic camera navigation (LCN) module was specifically developed for these key user groups. This multicenter prospective cohort study assesses face validity and construct validity of the LCN module on the Simendo virtual reality simulator. Face validity was assessed through a questionnaire on resemblance to reality and perceived usability of the instrument among experts and trainees. Construct validity was assessed by comparing scores of groups with different levels of experience on outcome parameters of speed and movement proficiency. The results obtained show uniform and positive evaluation of the LCN module among expert users and trainees, signifying face validity. Experts and intermediate experience groups performed significantly better in task time and camera stability during three repetitions, compared to the less experienced user groups (P < .007). Comparison of learning curves showed significant improvement of proficiency in time and camera stability for all groups during three repetitions (P < .007). The results of this study show face validity and construct validity of the LCN module. The module is suitable for use in training curricula for operating room nurses and novice surgical trainees, aimed at improving team performance in minimally invasive surger

Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: A Delphi approach

Background. Although task training on virtual reality (VR) simulators has been shown to transfer to the operating room, to date no VR curricula have been described for advanced laparoscopic procedures. The purpose of this study was to develop a proficiency-based VR technical skills curriculum for laparoscopic colorectal surgery. Methods. The Delphi method was used to determine expert consensus on which VR tasks (on the LapSim simulator) are relevant to teaching laparoscopic colorectal surgery. To accomplish this task, 19 international experts rated all the LapSim tasks on, a Likert scale (1-5) with respect to the degree to which they thought that a particular task should be included in a final technical skills curriculum. Results of the survey were sent back to participants until consensus (Cronbach's alpha > 0.8) was reached. A crass-sectional design was utilized to define the benchmark scores for the identified tasks. Nine expert surgeons completed all identified tasks on the "easy," "medium," and "hard" settings of the simulator Results. In the first round of the survey, Cronbach's alpha was 0.715; after the second round, consensus was reached at 0.865. Consensus was reached for T basic tasks and I advanced suturing task. Median expert time and economy of movement scores were defined as benchmarks for all curricular tasks. Conclusion. This study used Delphi consensus methodology to create a curriculum for an advanced laparoscopic procedure that is reflective of current clinical practice on an international level and conforms to current educational standards of proficiency-based training. (Surgery 2012;151:391-7.

A systematic review on the effect of serious games and wearable technology used in rehabilitation of patients with traumatic bone and soft tissue injuries

To determine the effects on functional outcomes and treatment adherence of wearable technology and serious games (i.e., interactive computer applications with specific purposes useful in the 'real world') currently applied in physical rehabilitation of patients after traumatic bone and soft tissue injuries. PubMed, Embase, the Cochrane Library and CINAHL were searched without publication date restrictions for the terms 'wearable', 'serious game', 'videogame' or 'mobile application', and 'rehabilitation', 'exercise therapy' or 'physiotherapy'. The search yielded 2704 eligible articles, which were screened by two independent reviewers. Studies comparing a serious game to standard therapy were included. Methodology and results of the studies were critically appraised in conformity with PRISMA guidelines. Twelve articles were included, all of which tested 'off-the-shelf' games. No studies on 'wearable-controlled' games, or games specifically developed for rehabilitation could be included. Medical conditions included post-operative rehabilitation and acute traumatic injuries. All studies were of low to moderate quality. Only two studies found beneficial effects of serious games over conventional therapy. One of three studies reporting pain scores found beneficial effects of a serious game compared to physiotherapy. One out of five trials reporting treatment adherence found a statistically significant advantage in the game-group compared to conventional physiotherapy. Due to heterogeneity in study design and outcome measures, pooling of data was not possible. Serious games seem a safe alternative or addition to conventional physiotherapy after traumatic bone and soft tissue injury. Future research should determine their validity and effectiveness in rehabilitation therapy, next to their cost-effectiveness and effect on treatment adherenc