Colonoscopic-Assisted Laparoscopic Wedge Resection for Colonic Lesions A Prospective Multicenter Cohort Study (LIMERIC-Study)

Objective: The aim of this study was to evaluate the safety and efficacy of a modified CAL-WR. Summary Background Data: The use of segmental colectomy in patients with endoscopically unresectable colonic lesions results in significant morbidity and mortality. CAL-WR is an alternative procedure that may reduce morbidity. Methods: This prospective multicenter study was performed in 13 Dutch hospitals between January 2017 and December 2019. Inclusion criteria were (1) colonic lesions inaccessible using current endoscopic resection techniques (judged by an expert panel), (2) non-lifting residual/recurrent adenomatous tissue after previous polypectomy or (3) an undetermined resection margin after endoscopic removal of a low-risk pathological T1 (pT1) colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated. Results: Of the 118 patients included (56% male, mean age 66 years, standard deviation +/- 8 years), 66 (56%) had complex lesions unsuitable for endoscopic removal, 34 (29%) had non-lifting residual/recurrent adenoma after previous polypectomy and 18 (15%) had uncertain resection margins after polypectomy of a pT1 colon carcinoma. CAL-WR was technically successful in 93% and R-0 resection was achieved in 91% of patients. Minor complications (Clavien-Dindo i-ii) were noted in 7 patients (6%) and an additional oncologic segmental resection was performed in 12 cases (11%). Residual tissue at the scar was observed in 5% of patients during endoscopic follow-up. Conclusions: CAL-WR is an effective, organ-preserving approach that results in minor complications and circumvents the need for major surgery. CAL-WR, therefore, deserves consideration when endoscopic excision of circumscribed lesions is impossible or incomplete.Cellular mechanisms in basic and clinical gastroenterology and hepatolog

Evaluation of national surgical practice for lateral lymph nodes in rectal cancer in an untrained setting

Background. Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level.Methods. Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (=7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those undergoing only rectal resection.Results. Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874).Conclusion. Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research

Virtual reality training and equipment handling in laparoscopic surgery

Laparoscopic surgery is one of the most important surgical innovations of the 20th century. Despite the well-known benefits for the patient, such as reduced pain, reduced hospital stay and quicker return to normal physical activities, there are also some drawbacks. Performing laparoscopic surgery requires specific psychomotor skills and extensive training. Furthermore, training solely on patients is considered unethical and therefore no longer acceptable. Besides the specific psychomotor skills required for laparoscopic surgery, its technical equipment has made the surgical environment more complex and has introduced new risks for the patients safety. The first objective of this thesis is the validation of the VR simulator SIMENDO for the training of laparoscopic psychomotor skills, in order to incorporate this simulator effectively into the surgical curriculum. The second objective of this thesis is the determination of the current problems and needs encountered during laparoscopic surgery in the operation room in order to develop methods to improve safety and efficiency. Validation of the SIMENDO VR simulator. The SIMENDO simulator was subjectively evaluated by a group of experienced laparoscopic surgeons and a group of surgical trainees, inexperienced with laparoscopic surgery (face validation). The groups considered the SIMENDO to be a useful simulator for the training of hand-eye coordination skills for laparoscopic surgery. The learning effect of a simple hand-eye coordination task in the SIMENDO with a single instrument was comparable to the learning effect of a similar task in a box trainer (concurrent validation). The parameters of the tasks in the simulator could distinguish groups with different laparoscopic experience levels (construct validation). The learning curve showed that training on the SIMENDO is useful and valid for subjects with limited or no laparoscopic experience. Training laparoscopic skills on a simulator distributed over several days seems better than training on just one day. Criterion-based training was successfully incorporated in the surgical curriculum. Laparoscopic knot-tying skills acquired on the simulator were shown to be transferable to the knot-tying performance on an animal model. In a randomised controlled trial, subjects that were trained on the VR simulator with the knot-tie module were 30% faster and made 33% fewer errors (transfer or predictive validity) in a laparoscopic animal model, as compared to the control group. Furthermore, a national on-line competition with a reward for the best performance was initiated. The use of competition elements on the simulator may enhance the motivation of surgical trainees to train voluntary. Current problems and needs during laparoscopic surgery in the operating room Analysis of 30 laparoscopic cholecystectomies showed that the incidence of problems with the technical equipment was strikingly high (49 incidents in 30 procedures, only four procedures without technical problems). These problems could be prevented by improvement and standardisation of equipment, in combination with the incorporation of a checklist before the start of the procedure. A structured checklist was developed to prevent incidents with laparoscopic equipment. In the group with the checklist the number of equipment problems decreased with more than 50% compared to the procedures studied previously without the checklist. To gain insight into the communication content during surgical training in the operation room, a classification method was developed. The application revealed that communication was mainly focussed on explaining of the operation method (27%), explaining the anatomy (19%), and learning the positioning of the instrument and how to interact with the tissue (25%). The results of the study may be used to specify training needs and to evaluate different training methods.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

The influence of different training schedules on the learning of psychomotor skills for endoscopic surgery

Applied Science

Requirements for the design and implementation of checklists for surgical processes

Background- The use of checklists is a promising strategy for improving patient safety in all types of surgical processes inside and outside the operating room. This article aims to provide requirements and implementation of checklists for surgical processes. Methods- The literature on checklist use in the operating room was reviewed based on research using Medline, Pubmed, and Google Scholar. Although all the studies showed positive effects and important benefits such as improved team cohesion, improved awareness of safety issues, and reduction of errors, their number still is limited. The motivation of team members is considered essential for compliance. Currently, no general guidelines exist for checklist design in the surgical field. Based on the authors’ experiences and on guidelines used in the aviation industry, requirements for the checklist design are proposed. The design depends on the checklist purpose, philosophy, and method chosen. The methods consist of the ‘‘call-doresponse’’ approach,’’ the ‘‘do-verify’’ approach, or a combination of both. The advantages and disadvantages of paper versus electronic solutions are discussed. Furthermore, a step-by-step strategy of how to implement a checklist in the clinical situation is suggested. Conclusions- The use of structured checklists in surgical processes is most likely to be effective because it standardizes human performance and ensures that procedures are followed correctly instead of relying on human memory alone. Several studies present promising and positive first results, providing a solid basis for further investigation. Future research should focus on the effect of various checklist designs and strategies to ensure maximal compliance.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

Construct validity and assessment of the learning curve for the SIMENDO endoscopic simulator

Mechanical, Maritime and Materials Engineerin

Transfer validity of laparoscopic knot-tying training on a VR simulator to a realistic environment: A randomized controlled trial

Background- Laparoscopic suturing is one of the most difficult tasks in endoscopic surgery, requiring extensive training. The aim of this study was to determine the transfer validity of knot-tying training on a virtual-reality (VR) simulator to a realistic laparoscopic environment. Methods- Twenty surgical trainees underwent basic eye–hand coordination training on a VR simulator (SIMENDO, DelltaTech, Delft, the Netherlands) until predefined performance criteria were met. Then, they were randomized into two groups. Group A (the experimental group) received additional training with the knot-tying module on the simulator, during which they had to tie a double laparoscopic knot ten times. Group B (controls) did not receive additional manual training. Within a week the participants tied a double knot in the abdominal cavity of an anaesthetized porcine model. Their performance was captured on digital video and coded. Objective analysis parameters were: time taken to tie the knot and number of predefined errors made. Subjective assessments were also made by two laparoscopic surgeons using a global rating list with a five-point Likert scale. Results- Trainees in group A (n = 9) were significantly faster than the controls (n = 10), with a median of 262 versus 374 seconds (p = 0.034). Group A made a significantly lower number of errors than the controls (median of 24 versus 36 errors, p = 0.030). Subjective assessments by the laparoscopic experts did not show any significant differences in economy of movement and erroneous behavior between the two groups. Conclusion- Surgical trainees who received knot-tying training on the VR simulator were faster and made fewer errors than the controls. The VR module is a useful tool to train laparoscopic knot-tying. Opportunities arose to improve simulator-based instruction that might enhance future training.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: A retrospective cohort study

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