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Objective: No standardization of quality of operative reporting currently exists, and this represents a missed opportunity for communication among health care providers. This study proposed a method to improve operative notes by structuring the findings by six anatomical zones of the pelvis. Objective I was to validate the method of documenting six zones of the pelvis by using intraoperative photography. Objective II was to compare this method with dictations from operative reports created before introducing this method., Methods: This retrospective cohort study evaluated pre- and post-intervention results of using six zones to guide operative reporting. Reports were collected from participating surgeons and were scored using a validated scoring tool. Each participant was taught to photograph six zones and use the zones in the operative report. Pre- and post-intervention cases were compared using generalized linear mixed models., Results: Scores of study participants using the zones were significantly higher than those without (P <0.0001). Surgeons showed an ability to improve their reporting. The detail illustrated in the cases was qualitatively richer, and the anatomy within the six zones was referenced more frequently., Conclusion: Compared with reports without the technique, incorporating the six zones greatly enhances operative reporting and likely would improve communication among care providers. More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Background: Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population., Objective: The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population., Study Design: We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively., Results: All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems., Discussion: Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele., Conclusion: On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Background: Sleeve gastrectomy is a relatively new procedure that developed as a result of rapid innovation in the field of bariatric surgery. As with any newly developed operation, there is a learning curve that potentially can be associated with higher morbidity. Real-time surgical mentoring reduces the learning curve effect but can be time intensive for the mentor. The aim of this initiative was to evaluate the feasibility, effectiveness, and satisfaction of surgical telementoring for laparoscopic sleeve gastrectomy. This is the first national specialty society effort to determine if the "remote presence" of an expert surgeon (mentor) can help practicing surgeons improve skills., Methods: The experience of 15 surgical trainees (mentees) who performed laparoscopic sleeve gastrectomy under real-time telementoring by 7 mentors was reviewed. Telementoring was implemented using the Visitor1 ® remote presence system with two-way live audio and video communication. The receiving platform utilized a conventional laptop, iPad, or iPhone. The mentee followed a structured telementoring program including didactic learning, live case teleobservation, and telementoring of 2-3 cases. A survey on the quality of the telecommunication and effectiveness of the mentoring was performed by the mentor and mentee on a scale of "exceeded," "met," "almost met," or "failed to meet" expectations. The overall telementoring experience was rated on a scale of 1 for "poor" to 5 for "excellent.", Results: Based on the mentees' survey, the overall telementoring experience was rated as 4.8. Despite the mentees having experience with laparoscopic sleeve gastrectomy, most commented that the telementoring experience was an excellent educational tool and they learned some new techniques they plan to apply it in their practice. Based on the mentors' survey, the overall telementoring experience was rated as 4.7. All mentors stated that they were satisfied with the telementoring sessions and there were no unexpected intraoperative occurrences. There were some logistical limitations including difficulties in scheduling of cases or the delay of cases., Conclusions: Surgical instruction by telementoring was shown to be feasible, practical, and successful, and was highly rated in this study by both the mentors and mentees. The currently utilized telementoring platform is thus an effective educational tool that can facilitate acquisition of surgical skills and assist with the conventional on-site surgical mentoring model.

Aim: To develop system for students training in laparoscopic surgery by using of Wet-lab educational operating theatre., Material and Methods: We have launched laparoscopic surgery teaching program for students of Ryazan State Medical University. This system includes several stages. At the first stage professional selection was carried out on 'dry' laparoscopic simulators among III-IV-year students of medical faculty. So, 10 people were selected. The second stage included theoretical and practical parts consisting of development of basic laparoscopic skills on 'dry' simulators. 5 students who scored the maximum points were admitted to the next stage. The third stage is working in Wet-lab operating theatre with a mentor. There were 10 sessions on 10 laboratory pigs. Final stage of our study compares two groups of participants: main group - 5 students who underwent above-described program and control group of 5 residents without experience for laparoscopic operations., Results: The participants of the main group had significantly higher OSATS score compared with another group (20 vs. 10; p<0.05). Movements effectiveness estimated by measuring of movements trajectory total length was also higher in main group than in control group (6 vs. 20; p<0.05). Experts' subjective assessment according to 10-point scale was also higher for students than for interns (9 vs. 5, p<0.05). Participants in the main group required significantly less time to complete the task compared with the control group (40 vs. 90 minutes, p<0.05)., Conclusion: Our experience has shown that training system with Wet-lab operating theatre is effective for quick and efficient training of medical students in main laparoscopic procedures. In our opinion, introduction of students into 'advanced' surgery from early age will make it possible to get finally highly professional specialists.

Background: With experience, certain psychomotor skills should translate from standard laparoscopy to single-incision laparoscopy (SIL). We proposed to compare all surgical postgraduate year (PGY) levels and determine if experience translated to improved SIL skills., Methods: Surgical residents of all PGY levels (1-5) at our institution were included. Baseline surveys were obtained to determine resident level of exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel, endoloop placement, extracorporeal suture tying, and intracorporeal suture tying. Tasks were performed on a commercially provided simulated inanimate organ model. Participants were given 5 min to complete each task. Data were collected and analyzed by an impartial-certified Fundamentals of Laparoscopic Surgery proctor., Results: A total of 31 residents participated in the study. Overall, there was minimal SIL exposure among all residents. As expected, PGY level correlated with increased ability to complete assigned tasks within the allotted time. There was a statistically significant difference in the number of individuals able to complete a task based on PGY level for all given tasks (P = 0.005). With increased difficulty, the percentage of higher level residents able to complete the task decreased (100% PGY5 completed running of bowel versus 0% intracorporeal knot tying)., Conclusions: Certain psychomotor skills did appear to translate to SIL skills. However, further dedicated SIL training may help to better develop certain laparoscopic skills devoted to SIL., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The aim of this study is to examine operative flow disruption that occurs inside the surgical field, (internal operative flow disruption (OFD)), during urological laparoscopies, and to relate those events to external ergonomics environment in terms of monitor location, level of instruments' handles, and location of surgical team members. According to the our best knowledge, this is the first study of its kind., Methods: A combination of real and video-aided observational study was conducted in the operating rooms at hospitals in Australia and China. Brain storming sessions were first conducted to identify the main internal OFD events, and the observable reasons, potential external, and latent ergonomic factors were listed. A prospective observational study was then conducted. The observer's records and the related video records of internal surgical fields were analysed. Procedures were categorised into groups based on similarity in ergonomics environment., Results: The mapping process revealed 39 types of internal OFD events resulted from six reasons. A total of 24 procedures were selected and arranged into two groups, each with twelve procedures. Group A was carried out under satisfactory ergonomics environment, while Group B was conducted under unsatisfactory ergonomics environment. A total of 1178 OFD events were detected delaying the total observed operative times (2966 min) by 220 min (7.43%). Average OFD/h in group A was less than 15, while in group B about 29 OFD/h., Conclusion: There are two main latent ergonomics factors affecting the surgeon's performance; non-physiological posture and long-period static posture. The delays and number of internal OFD were nearly doubled where procedures were conducted under unsatisfactory external ergonomics environment. Some events such as stopping operation and irrelevant conversations during long procedures may have a positive influence on the surgeon's performance.

Background: Distractions such as phone calls during laparoscopic surgery play an important role in many operating rooms. The aim of this single-centre, prospective study was to assess if laparoscopic performance is impaired by intraoperative phone calls in novice surgeons., Methods: From October 2015 to June 2016, 30 novice surgeons (medical students) underwent a laparoscopic surgery training curriculum including two validated tasks (peg transfer, precision cutting) until achieving a defined level of proficiency. For testing, participants were required to perform these tasks under three conditions: no distraction (control) and two standardised distractions in terms of phone calls requiring response (mild and strong distraction). Task performance was evaluated by analysing time and accuracy of the tasks and response of the phone call., Results: In peg transfer (easy task), mild distraction did not worsen the performance significantly, while strong distraction was linked to error and inefficiency with significantly deteriorated performance (P < 0.05). Precision cutting (difficult task) was not slowed down by mild distraction, but surgical and cognitive errors were significantly increased when participants were distracted (P < 0.05). Compared to mild distraction, participants reported a more severe subjective disturbance when they were diverted by strong distraction (P < 0.05)., Conclusion: Our data reveals that phone call distractions result in impaired laparoscopic performance under certain circumstances. To ensure patient safety, phone calls should be avoided as far as possible in operating rooms.

Background: Laparoscopic donor nephrectomy (LDN) is the standard of care for donor nephrectomies. No large series reports have been published detailing the LDN experience of minimally invasive general surgeons., Methods: A retrospective review of 526 LDNs performed by MIS general surgeons at Baylor University Medical Center between 1999 and 2013. Complications were graded on the Clavien scale. The learning curve was determined by procedure time., Results: The complication rate was 3.0%. Female donors had shorter operative time than males (141 vs 162 min). Warm ischemia time was shorter with female donors and left kidney procurement. There were six recipient graft losses within 30 days of the transplant. Operative time plateaued after 27 cases., Conclusion: MIS general surgeons using a standardized technique can learn and perform a new, unfamiliar procedure with excellent results. Women are easier to perform organ harvest than men. Organ harvest from obese patients can be safely performed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE To determine whether basic laparoscopic skills acquired during training in the horizontal plane would transfer to the vertical plane and vice versa. DESIGN Evaluation study. SAMPLE POPULATION 26 first- and second-year veterinary students with no prior laparoscopic skills training or surgical experience. PROCEDURES Participants were nonrandomly assigned to 2 groups. Group 1 (n = 15) underwent laparoscopic skills training in the horizontal plane, and group 2 (17) underwent laparoscopic skills training in the vertical plane. Following training, participants were tested on their ability to perform 5 laparoscopic tasks, first in the horizontal plane and then the vertical plane (group 1) or first in the vertical plane and then in the horizontal plane (group 2). All training and testing were performed with an augmented-reality laparoscopic simulator. RESULTS 3 participants in each group did not complete the study. For group 1, scores for 3 of the 5 tasks were significantly worse when tested in the vertical plane than when tested in the horizontal plane. For group 2, scores for 2 of the 5 tasks were significantly worse when tested in the horizontal plane than when tested in the vertical plane. For 3 tasks, the difference in scores for the training versus orthogonal plane was significantly lower for group 2 than for group 1. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that basic laparoscopic skills acquired in 1 plane frequently did not transfer to the orthogonal plane. Because veterinary surgeons may be required to treat patients in various positions, development of laparoscopic training models to simulate the vertical plane is recommended.

Background: While simulation training has been established as an effective method for improving laparoscopic surgical performance in surgical residents, few studies have focused on its use for attending surgeons, particularly in obstetrics and gynecology. Surgical simulation may have a role in improving and maintaining proficiency in the operating room for practicing obstetrician gynecologists., Objective: We sought to determine if parameters of performance for validated laparoscopic virtual simulation tasks correlate with surgical volume and characteristics of practicing obstetricians and gynecologists., Study Design: All gynecologists with laparoscopic privileges (n = 347) from 5 academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a presimulation survey gathering physician self-reported characteristics and then performed 3 basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) on the LapSim virtual reality laparoscopic simulator (Surgical Science Ltd, Gothenburg, Sweden). The association between simulation outcome scores (time, efficiency, and errors) and self-rated clinical skills measures (self-rated laparoscopic skill score or surgical volume category) were examined with regression models., Results: The average number of laparoscopic procedures per month was a significant predictor of total time on all 3 tasks (P = .001 for peg transfer; P = .041 for lifting and grasping; P < .001 for cutting). Average monthly laparoscopic surgical volume was a significant predictor of 2 efficiency scores in peg transfer, and all 4 efficiency scores in cutting (P = .001 to P = .015). Surgical volume was a significant predictor of errors in lifting/grasping and cutting (P < .001 for both). Self-rated laparoscopic skill level was a significant predictor of total time in all 3 tasks (P < .0001 for peg transfer; P = .009 for lifting and grasping; P < .001 for cutting) and a significant predictor of nearly all efficiency scores and errors scores in all 3 tasks., Conclusion: In addition to total time, there was at least 1 other objective performance measure that significantly correlated with surgical volume for each of the 3 tasks. Higher-volume physicians and those with fellowship training were more confident in their laparoscopic skills. By determining simulation performance as it correlates to active physician practice, further studies may help assess skill and individualize training to maintain skill levels as case volumes fluctuate., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To define "best possible" outcomes in total minimally invasive transthoracic esophagectomy (ttMIE)., Background: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy., Patients and Methods: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ≤2, WHO/ECOG score ≤1, age ≤65 years, body mass index 19-29 kg/m). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results., Results: Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53-62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0-2) and 12 (9-18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ≤55.7% and ≤30.8% for overall and major complications, ≤18.0% for readmission, ≤3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ≤1.0% and ≤4.6% for mortality, and ≤40.8 and ≤42.8 for the comprehensive complication index, respectively., Conclusion: This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.

Objective: Fundamentals of laparoscopic surgery (FLS) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to teach the physiology, fundamental knowledge, and technical skills required for basic laparoscopic surgery. We hypothesize that residents are doing more laparoscopic surgery earlier in residency, and therefore would benefit from an earlier assessment of basic laparoscopic skills. Here, we examine FLS test results and ACGME case logs to determine whether it is practical to administer FLS earlier in residency., Design: FLS test results were reviewed for the 42 residents completing FLS between July 2011 and July 2016. ACGME case logs for current and former residents were reviewed for laparoscopic cases logged by each postgraduate year. Basic and complex laparoscopic cases were determined by ACGME General Surgery Defined Category and Minimums Report. Descriptive statistics were used for analysis., Setting: Academic general surgery residency, Washington University in St. Louis School of Medicine., Participants: Current and former general surgery residents., Results: A total of 42 residents took and passed FLS between July 2011 and July 2016. All residents successfully passed the FLS knowledge and skills examinations on the first attempt regardless of their postgraduate year (PGY 3n = 13, PGY 4n = 15, and PGY 5n = 14). Total laparoscopic case volume has increased over time. Residents who graduated in 2012 or 2013 completed 229 laparoscopic cases compared to 267 laparoscopic cases for those who graduated from 2014 to 2016 (p = 0.02). Additionally, current residents completed more laparoscopic cases in the first 2 years of residency than residents who graduated from 2012 to 2016 (median current = 38; former = 22; p < 0.001). Examining laparoscopic case numbers for current residents by PGY demonstrated that the number of total and complex laparoscopic cases increased in each of the first 3 years of residency with the largest increase occurring between the PGY 2 and PGY 3 years. In the PGY 4 and PGY 5 years, most laparoscopic cases were complex., Conclusion: Increased use of laparoscopic surgery has led to a corresponding increase in laparoscopic case volume among general surgery residents. We would advocate for FLS testing to serve as an early assessment of laparoscopic knowledge and skill and should be performed before a significant increase in complex laparoscopic surgery during training., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery., Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets., Results: The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group., Conclusion: IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted., (© 2017 Royal Australasian College of Surgeons.)

Randomized controlled trials have demonstrated that laparoscopic surgery for rectal cancer is safe and can accelerate recovery without compromising oncological outcomes. However, such a surgery is technically demanding, limiting its application in nonspecialized centers. The operational features of a robotic system may facilitate overcoming this limitation. Studies have reported the potential advantages of robotic surgery. However, only a few of them have featured the application of this surgery in patients with advanced rectal cancer undergoing neoadjuvant chemoradiation therapy (nCRT).From January 2012 to April 2015, after undergoing nCRT, 40 patients with mid or low rectal cancer were operated using the robotic approach at our institution. Another 38 patients who were operated using the conventional laparoscopic approach were matched to patients in the robotic group by sex, age, the body mass index, and procedure. All operations were performed by a single surgical team. The clinicopathological characteristics and short-term outcomes of these patients were compared. To assess the effect of the learning curve on the outcomes, patients in the robotic group were further subdivided into 2 groups according to the sequential order of their procedures, with an equal number of patients in each group. Their outcome measures were compared.The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, rectal resection type, and pathological examination result. After undergoing nCRT, more patients in the robotic group exhibited clinically advanced diseases. The complication rate was similar between the 2 groups. The operation time and the time to the resumption of a soft diet were significantly prolonged in the robotic group. Further analysis revealed that the difference was mainly observed in the first robotic group. No significant difference was observed between the second robotic and laparoscopic groups.Although the robotic approach may offer potential advantages for rectal surgery, comparable short-term outcomes may be achieved when laparoscopic surgery is performed by experienced surgeons. However, our results suggested a shorter learning curve for robotic surgery for rectal cancer, even in patients who exhibited more advanced disease after undergoing nCRT.

Objective: Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program., Design: A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts., Setting: Large university paediatric surgical service., Participant(s): All 153 managers and staff., Interventions: Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs., Main Outcome Measure(s): Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room)., Results: Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly., Conclusions: Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: This study addresses target group reliability and task validity for training on a laparoscopic simulator., Material and Methods: Data were collected on 64 participants prospectively at the Department of OB/GYN, University Hospitals Schleswig-Holstein, Campus Kiel. The Simbionix LAP Mentor for laparoscopic simulation was used to test trainees. Each participant received a questionnaire to clarify his/her medical position, surgical experience, and previous virtual reality (VR) experience, including video gaming experience. Pre- and post-tests were performed. Performances were analyzed for task completion and total time., Results: All participants revealed a significant improvement in the post-test compared with the pre-test (p < .005), independent of their previous level of experience. Regarding accomplishment of the assigned task, the experts revealed in the pre-test an advantage in tasks 1-4 and 6-8. The beginners revealed wide-ranging improvements in tasks 3, 5, 8, and 9 between the pre-test and the post-test compared with novices in laparoscopic surgery (residents), and a wide range of improvements relative to experts. VR experience and video gaming exposure revealed an advantage in the pre-test; however, participants without previous exposure were able to narrow the gap, revealing extensive improvements in the post-test., Conclusion: The trainer could be beneficial for medical students and surgical novices.

Objectives: The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach., Methods: We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared., Results: A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed., Conclusions: The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Uncontrolled introduction of laparoscopic liver surgery (LLS) could compromise postoperative outcomes. A stepwise introduction of LLS combined with structured training is advised. This study aimed to evaluate the impact of such a stepwise introduction., Methods: A retrospective, single-center case series assessing short term outcomes of all consecutive LLS in the period November 2006-January 2017. The technique was implemented in a stepwise fashion. To evaluate the impact of this stepwise approach combined with structured training, outcomes of LLS before and after a laparoscopic HPB fellowship were compared., Results: A total of 135 laparoscopic resections were performed. Overall conversion rate was 4% (n = 5), clinically relevant complication rate 13% (n = 18) and mortality 0.7% (n = 1). A significant increase in patients with major LLS, multiple liver resections, previous abdominal surgery, malignancies and lesions located in posterior segments was observed after the fellowship as well as a decrease in the use of hand-assistance. Increasing complexity in the post fellowship period was reflected by an increase in operating times, but without comprising other surgical outcomes., Conclusion: A stepwise introduction of LLS combined with structured training reduced the clinical impact of the learning curve, thereby confirming guideline recommendations., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: Staging laparoscopy (SL) is the gold standard investigation for detecting peritoneal metastases (PM) in patients with esophagogastric cancer but computed tomography (CT) has undergone significant improvements in recent years. The aim of this study was to investigate whether CT can replace SL in the detection of PM., Materials and Methods: Patients undergoing SL between January 2008 and December 2009 were identified from a prospectively collected database, operation notes were reviewed for the detection of PM. Corresponding CTs were reassessed by 2 experienced gastrointestinal radiologists, blinded to the SL results., Results: In total, 74 patients undergoing SL were included. Sensitivity and specificity of SL for PM were 94.1% (95% confidence interval, 69.2-99.7) and 100% (90.7-100). Sensitivity and specificity of CT were 58.8% (33.5-80.6) and 89.6% (76.6-96.1), respectively. Area under the curve of receiver operating characteristic curves for SL and CT were 0.971 (SE, 0.033) and 0.742 (SE, 0.78), respectively., Conclusions: CT cannot replace SL for the detection of PM in lower esophageal and gastric cancer.

Background: Hysterectomy is one of the most common surgical procedures for women of reproductive age. Laparoscopy was introduced in the 1990es and is today one of the recommended routes of surgery. A recent observational study showed that operative time for hysterectomy was significantly lower for 3-dimensional compared to conventional laparoscopy. Complication rates were similar for the two groups. No other observational studies or randomized clinical trials have compared 3-dimensional to conventional laparoscopy in patients undergoing total hysterectomy for benign disease. The objective of the study is to determine if 3D laparoscopy gives better quality of life, less postoperative pain, less per- and postoperative complications, shorter operative time, or a shorter stay in hospital and a faster return to work or normal life, compared to conventional laparoscopy for benign hysterectomy., Methods/design: The design is a randomised multicentre clinical trial. Participants will be 400 women referred for laparoscopic hysterectomy for benign indications. Patients will be randomized to 3-dimensional or conventional laparoscopic hysterectomy. Operative procedures will follow the same principles and the same standard whether the surgeon's vision is 3-dimensional or conventional laparoscopy. Primary outcomes will be the impact of surgery on quality of life, assessed by the SF 36 questionnaire, and postoperative pain, assessed by a Visual Analogue scale for pain measurement. With a standard deviation of 12 points on SF 36 questionnaire, a risk of type I error of 3.3% and a risk of type II error of 10% a sample size of 190 patients in each arm of the trial is needed. Secondarily, we will investigate operative time, time to return to work, length of hospital stay, and - and postoperative complications., Discussion: This trial will be the first randomized clinical trial investigating the potential clinical benefits and harms of 3-dimensional compared to conventional laparoscopy. The results may provide more evidence regarding the future place of 3-dimensional laparoscopy in the range of endoscopic approaches for benign hysterectomy., Trial Registration: This study is registered at ClinicalTrial.gov: NCT02610985 November 16th 2015. November 2015. The regional Ethical committee approved it on the 12. November 2015, approval number: SJ-498. Data handling was approved by the Danish Data Protection Agency: REG-109-2015 on the 13. November 2015.

Background: It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty., Methods: Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified., Results: Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase., Conclusions: Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.

Background: Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption., Objective: To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles., Patients and Methods: This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed., Results: The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient., Conclusion: Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting., (Copyright © 2017 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved.)

Study Objective: To describe the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy (TLH)., Design: Observational study (Canadian Task Force classification III)., Setting: Academic affiliated hospital., Patients: Thirty-one women undergoing TLH for benign indications in 2016., Interventions: After antibiotic prophylaxis and chlorhexidine preparation, swabs were collected from the vaginal fornices and abdomen. During subsequent TLH, additional swabs were collected from the following sites: surgeon's gloves after placement of the uterine manipulator, tips of instruments used to close the vaginal cuff, uterine fundus after extraction, and surgeon's gloves after removal of the uterus. A calibrated loop was used to inoculate each specimen onto 5% blood and chocolate agars for growth of aerobes and onto Brucella blood, phenylethyl alcohol, kanamycin vancomycin, and Bacteroides bile esculin agars for growth of anaerobes. Manual colony counts were tabulated for all positive cultures and reported in colony-forming units per milliliter (CFU/mL)., Measurements and Main Results: Anaerobic growth was not seen on the instrument tips, in the vagina, or on the abdomen of any patient. Aerobic bacterial growth was not seen in the vagina of any patient. On the surgeon's gloves after uterine manipulator placement, no patients demonstrated sufficient bacterial growth to potentially cause surgical site infection (≥5000 CFU/mL). On the surgeon's gloves following uterine extraction, 1 patient demonstrated sufficient growth to potentially cause infection. None of the patients developed surgical site infections postoperatively., Conclusion: Cultures from multiple operative sites yielded bacterial growth, but the bacterial concentrations did not exceed the threshold for infection in 98.9% of cultures. Given absent growth from vaginal cultures and rare growth from abdominal cultures, chlorhexidine gluconate 4% is considered an appropriate surgical preparation for use in laparoscopic hysterectomy., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

An experienced surgical team, in general, and the surgeon assistant in particular are believed to play a critical role in the operation's safety and success. We sought to explore whether the assistant's seniority influences perioperative course following robot assisted laparoscopic radical prostatectomy (RALP). We reviewed our prospective registry database of RALP cases performed by a single surgeon who during the study period was beyond his learning curve. The following parameters were documented and analyzed: patient's age, body mass index (BMI), associated comorbidities, previous abdominal surgeries, assistant's identity, total and skin-to-skin operative time (tOT, ssOT, respectively), estimated blood loss (EBL), immediate post-operative complications, length of stay (LOS), and prostate weight per final pathology report. Univariate analysis and Spearman's correlation test were used to evaluate whether the assistant's seniority influenced perioperative course. Between the years 2011-2015, 106 consecutive cases were retrieved and analyzed. Prostate weight was found to be associated with longer tOT (Spearman's ρ = 0.34, p < 0.001), ssOT (0.3, p < 0.01) and increased EBL (0.28, p < 0.01). Patient's age, BMI, associated comorbidities, and previous abdominal surgeries were found to have no influence on neither tOT, ssOT nor EBL. Three assistants' subgroups were identified (seniors, PGY 1-3, PGY 4-6). The assistant's seniority was found to have no influence on tOT, ssOT, EBL, immediate post-operative complications and LOS. Same results were obtained following prostate size adjustments. The assistant's seniority has no influence on perioperative course following RALP. Consequently, given a highly experienced primary surgeon, a less experienced assistant can be safely incorporated into this procedure.

Background: The question of assessing surgical competence is the focus of mainly Anglo-Saxon studies. The GOALS questionnaire (Global Operative Assessment of Laparoscopic Skills) specific to laparoscopic surgery assessment has been developed since 2005. The aim of the study was to assess the metrological qualities of the GOALS questionnaire after ratification in French language., Methods: To produce a French version of the GOALS surgical competence assessing tool according to an established method (translation - backward translation - retranslation) and to check the metrological qualities (user satisfaction, acceptability, reliability and validity) of this questionnaire through observing residents while in training program on 22 residents in Gynaecology Obstetrics during the laparoscopy training, with the performance of a nephrectomy on a porcine model., Results: The discrepancies in the initial translations were mainly due literal translations. Only synonymous differences were observed in the two backward translations. Comparison with original version led to 8 minor changes. No changes occurred between the 2 French versions. Satisfaction surveys when using the GOALS questionnaire by both examiners and students are similar. Face and content validity seemed good and there is no significant discrepancy between the examiners and the students (11.5 [9-15]; 12.4 [9-15]; P=0.40). Assessment by examiners showed an median value of 17.8 [9-26] with good correlation (α=0.80). By contrast, self-assessment, although there is no significant discrepancy, showed heterogeneity. GOALS French version was able to prove a significant progression both in self-assessment and external evaluation between the act performed on the first nephrectomy on the first day of the first session of the training and the fourth nephrectomy performed on the first day of the second session of the training., Conclusion: Our work allowed obtaining a GOALS French version with acceptable validity, good consistency between the assessments and ability to measure progress., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Laparoscopic surgery and robotic surgery, two forms of minimally invasive surgery (MIS), have recently experienced a large increase in utilization. Prior studies have shown that video game experience (VGE) may be associated with improved laparoscopic surgery skills; however, similar data supporting a link between VGE and proficiency on a robotic skills simulator (RSS) are lacking. The objective of our study is to determine whether volume or timing of VGE had any impact on RSS performance. Pre-clinical medical students completed a comprehensive questionnaire detailing previous VGE across several time periods. Seventy-five subjects were ultimately evaluated in 11 training exercises on the daVinci Si Skills Simulator. RSS skill was measured by overall score, time to completion, economy of motion, average instrument collision, and improvement in Ring Walk 3 score. Using the nonparametric tests and linear regression, these metrics were analyzed for systematic differences between non-users, light, and heavy video game users based on their volume of use in each of the following four time periods: past 3 months, past year, past 3 years, and high school. Univariate analyses revealed significant differences between heavy and non-users in all five performance metrics. These trends disappeared as the period of VGE went further back. Our study showed a positive association between video game experience and robotic skills simulator performance that is stronger for more recent periods of video game use. The findings may have important implications for the evolution of robotic surgery training.

Background: Inoperable hepatocellular carcinoma (HCC) can be treated with laparoscopic radiofrequency ablation (LRFA), which is generally a more accurate and accessible procedure than percutaneous RFA (PRFA). However, few studies have compared survival outcomes between LRFA and PRFA in patients with HCC., Aims: This study aimed to compare the efficacy of LRFA and PRFA for HCC treatment., Methods: Patients who underwent PRFA or LRFA as an initial treatment modality between April 2005 and April 2016 were enrolled in this study. The overall and recurrence-free survival rates were examined for each patient. Additionally, propensity score matching was performed for both groups., Results: The baseline characteristics of patients in the PRFA and LRFA groups showed several minor differences. Multivariate analysis showed that the RFA method was not a critical determinant of recurrence-free or overall survival (p = 0.069 and p = 0.406). Among patients who underwent RFA as the initial treatment modality, there was no significant effect between either RFA procedures on survival. After propensity score matching, univariate analysis showed a significant difference in overall survival between PRFA and LRFA (p = 0.031). Multivariate analysis showed that LRFA is a strong factor that contributed to an improved overall survival in HCC patients (hazard ratio 0.108, p = 0.040). Furthermore, our data showed that LRFA was able to limit multiple intrahepatic recurrences, as well as prevent marginal recurrence., Conclusions: LRFA appears to be superior to PRFA in terms of survival. LRFA may help reduce mortality in HCC patients.

Introduction: Video games are mainly considered to be of entertainment value in our society. Laparoscopic surgery and video games are activities similarly requiring eye-hand and visual-spatial skills. Previous studies have not conclusively shown a positive correlation between video game experience and improved ability to accomplish visual-spatial tasks in laparoscopic surgery. This study was an attempt to investigate this relationship., Aim: The aim of the study was to investigate whether previous video gaming experience affects the baseline performance on a laparoscopic simulator trainer., Materials and Methods: Newly qualified medical officers with minimal experience in laparoscopic surgery were invited to participate in the study and assigned to the following groups: gamers (n = 20) and non-gamers (n = 20). Analysis included participants' demographic data and baseline video gaming experience. Laparoscopic skills were assessed using a laparoscopic simulator trainer., Results: There were no significant demographic differences between the two groups. Each participant performed three laparoscopic tasks and mean scores between the two groups were compared. The gamer group had statistically significant better results in maintaining the laparoscopic camera horizon ± 15° (p value = 0.009), in the complex ball manipulation accuracy rates (p value = 0.024) and completed the complex laparoscopic simulator task in a significantly shorter time period (p value = 0.001). Although prior video gaming experience correlated with better results, there were no significant differences for camera accuracy rates (p value = 0.074) and in a two-handed laparoscopic exercise task accuracy rates (p value = 0.092)., Conclusion: The results show that previous video-gaming experience improved the baseline performance in laparoscopic simulator skills., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To describe a standard reproducible technique for simple robotic- assisted laparoscopic trachelectomy., Design: Step-by-step demonstration of the technique using videos and pictures (Canadian Task Force classification level 3)., Setting: The incidence of trachelectomy after supracervical hysterectomy has been increasing, given the popularity of supracervical hysterectomy. The most common indication for trachelectomy is symptomatic cyclic bleeding. Trachelectomy can be performed vaginally as well as laparoscopically with or without robotic assistance. This video demonstrates a standard reproducible technique for robotic-assisted trachelectomy in 2 women who underwent previous supracervical hysterectomy with a retained cervix., Interventions: Robotic-assisted laparoscopic trachelectomy using a standard technique is demonstrated in 2 different examples. The steps include opening the vesicocervical peritoneum, creating a bladder flap and pushing the bladder down beyond the vaginal cuff, opening the remnant of the broad ligament and delineating the course of cervical branch of the uterine artery and ureter bilaterally, inserting a uterine manipulator with a colpotomizer under vision, performing desiccation of the cervical branches of the uterine artery, and performing colpotomy and closure of the vaginal cuff., Conclusion: Robotic-assisted laparoscopic trachelectomy is a safe and simple procedure that should be part of all general gynecologists' armamentarium. The described technique is reproducible and efficient and can be adopted for all cases requiring simple trachelectomy., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient's legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is "from left to right", "from proximal to distal" and "from inferior to superior". Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized: the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient's position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient's posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.

Objective: To investigate whether laparoscopic excision of ovarian endometriomas pretreated with operation by gynecologists or reproductive surgeons exerts different effects on in vitro fertilization-intracytoplasmic sperm injection results., Materials and Methods: Retrospective case control study. Relevant information was collected from the electronic records of women who underwent IVF/ICSI from 01/01/2013 to 30/12/2015 in our unit. The study group consisted of 35 women who previously had laparoscopic endometrioma excision by reproductive surgeons in our unit; the control group included 36 patients who underwent surgery for endometriomas by gynecologists in our hospital., Result(s): There were slightly higher numbers of AFC and higher pregnancy rate in the study group, although differences did not reach statistical significance. For patients over 35 years old, there were more oocyte retrieved, mature oocytes and two pronucei (2PN) in the study group than the control group although observed differences did not reach statistical significance., Conclusion(s): Electrocautery is more deleterious on ovarian reserve than hemostatic suture. In procedure of patients who wish to conceive, surgeons should use hemostatic suturing technique preferentially.

Purpose of Review: There has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon., Recent Findings: A structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice. Robotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.

Background: This study aimed to standardize the surgical correction technique of congenital Morgagni diaphragmatic hernia (CMDH), analyzing the results of an international multicentric survey., Methods: The medical records of 43 patients (29 boys, 14 girls) who underwent laparoscopic repair of CMDH in 8 pediatric surgery units in a 5-year period were retrospectively reviewed. Their average age was 3.3 years. Ten patients (23.2%) presented associated malformations: 9 Down syndrome (20.9%) and 1 palate cleft (2.3%). Thirty-five patients (81.4%) were asymptomatic, whereas 8 patients (18.6%) presented symptoms such as respiratory distress, cough or abdominal pain. As for preoperative work-up, all patients received a chest X-ray (100%), 15/43 (34.8%) a CT scan, 8/43 (18.6%) a barium enema and 4/43 (9.3%) a US., Results: No conversion to open surgery was reported. Average operative time was 61.2 min (range 45-110 min). In 38/43 (88.3%) patients, a trans-parietal stitch was positioned in order to reduce the tension during the repair. In 14/43 cases (32.5%), the sac was resected; in only 1/43 case (2.3%) a dual mesh of goretex was adopted to reinforce the closure. Average hospital stay was 2.8 days. The average follow-up was 4.2 years, and it consisted in annual clinical controls and chest X-ray. We recorded 2 complications (4.6%): one small pleural opening that required no drain and one recurrence (2.3%), re-operated in laparoscopy, with no further recurrence., Conclusions: To the best of our knowledge, this is the largest series published in the literature on this topic. Laparoscopic CMDH repair is well standardized: The full-thickness anterior abdominal wall repair using non-resorbable suture with interrupted stitches is the technique of choice. Postoperative outcome was excellent. Recurrence rate was very low, about 2% in our series. We believe that children with CMDH should be always treated in laparoscopy following the technical details reported in this paper.

Purpose: Complete mesocolic excision (CME) with central vascular ligation (CVL) has been widely accepted as a surgical treatment for right-sided colon cancer. Single-site laparoscopic colectomy (SLC) is associated with reduced pain and improved cosmesis, in comparison to the multi-site laparoscopic colectomy (MCL). Although the feasibility of CME + CVL under MCL has been reported, SLC for right-sided colon cancer is generally challenging. The purpose of this study is to demonstrate our efforts to standardize the SLC for right-sided colon cancer., Methods: This retrospective study enrolled 202 consecutive patients with right-sided colon cancer who underwent laparoscopic colectomy for right-sided colon cancer, using an inferior approach and intraoperative navigation surgery, between 2008 and 2014. The patients were divided into 3 groups, based on the period of treatment, as follows: Period I (2008-2009, n = 56), Period II (2010-2011, n = 70), and Period III (2012-2014, n = 76)., Results: The patient's baseline characteristics did not differ among the three periods. The ratio of SLC significantly increased with the passage of the time. The short-term outcomes were similar among the three periods. As for oncological clearance, there was a significant increase in the number of resected lymph nodes with the passage of the time (P < 0.05)., Conclusions: We successfully standardized SLC for right-sided colon cancer.

Background: Surgical checklists are used for error reduction. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to study the effect of a self-administered checklist on the laparoscopic task performance of novices during a standardized task., Methods: Twenty novices were randomized into 2 equal groups, those receiving paper feedback (control group) and those receiving paper feedback and the checklist (checklist group). Subjects performed laparoscopic double knots, repeated over 5 separate stages. Human reliability assessment technique was used for error analysis., Results: 2,341 errors were detected during the 5 stages. During the first stage, the errors were not significantly different between the 2 groups. The checklist group committed significantly fewer errors as compared with the control group during all the later 4 stages (P < .01)., Conclusions: The simple intraprocedural checklist significantly improved the laparoscopic task performance and the learning curve of laparoscopic novices., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Outcomes of surgical trials hinge on surgeon selection and their underlying expertise. Assessment of expertise is paramount. We investigated whether surgeons' performance measured by the fundamentals of laparoscopic surgery (FLS) assessment program could predict their performance in a surgical trial., Methods: As part of a prospective multi-institutional study of minimally invasive inguinal lymphadenectomy (MILND) for melanoma, surgical oncologists with no prior MILND experience underwent pre-trial FLS assessment. Surgeons completed MILND training, began enrolling patients, and submitted videos of each MILND case performed. Videos were scored with the global operative assessment of laparoscopic skills (GOALS) tool. Associations between baseline FLS scores and participant's trial performance metrics were assessed., Results: Twelve surgeons enrolled patients; their median total baseline FLS score was 332 (range 275-380, max possible 500, passing >270). Participants enrolled 87 patients in the study (median 6 per surgeon, range 1-24), of which 72 (83%) videos were adequate for scoring. Baseline GOALS score was 17.1 (range 9.6-21.2, max possible score 30). Inter-rater reliability was excellent (ICC = 0.85). FLS scores correlated with improved GOALS scores (r = 0.57, p = 0.05) and with decreased operative time (r = -0.6, p = 0.02). No associations were found with the degree of patient recruitment (r = 0.02, p = 0.7), lymph node count (r = 0.01, p = 0.07), conversion rate (r = -0.06, p = 0.38) or major complications(r = -0.14, p = 0.6)., Conclusions: FLS skill assessment of surgeons prior to their enrollment in a surgical trial is feasible. Although better FLS scores predicted improved operative performance and operative time, other trial outcome measures showed no difference. Our findings have implications for the documentation of laparoscopic expertise of surgeons in practice and may allow more appropriate selection of surgeons to participate in clinical trials.

Peritoneal dialysis (PD) is an effective renal replacement therapy for the treatment of end-stage renal disease. Patients on PD undergoing abdominal open surgery often fail to resume PD. Laparoscopic surgery has recently become a serious alternative to open surgery in patients on PD to treat different abdominal pathologies. However, only a few studies have reported successful procedures without Tenckhoff catheter removal. The aim of this review is to describe how a laparoscopic technique can allow PD patients to deal with abdominal surgery without shifting to hemodialysis. Only 50 cases of laparoscopic surgical intervention in PD patients have been published to our knowledge. These case series largely concern laparoscopic cholecystectomies, appendectomies, nephrectomies, colectomies, and bariatric procedures. The reported cases show how laparoscopic surgery can be accepted as a valid option for several abdominal surgical procedures in patients on PD with good outcomes and early resumption of PD.

Background: Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC)., Objectives: This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC., Results: RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated., Conclusion: The evidence in regard to controversial points remains limited.

Background: This study compared precision of depth judgements, technical performance and workload using two-dimensional (2D) and three-dimensional (3D) laparoscopic displays across different viewing distances. It also compared the accuracy of 3D displays with natural viewing, along with the relationship between stereoacuity and 3D laparoscopic performance., Methods: A counterbalanced within-subjects design with random assignment to testing sequences was used. The system could display 2D or 3D images with the same set-up. A Howard-Dolman apparatus assessed precision of depth judgements, and three laparoscopic tasks (peg transfer, navigation in space and suturing) assessed performance (time to completion). Participants completed tasks in all combinations of two viewing modes (2D, 3D) and two viewing distances (1 m, 3 m). Other measures administered included the National Aeronautics and Space Administration Task Load Index (perceived workload) and the Randot ® Stereotest (stereoacuity)., Results: Depth judgements were 6·2 times as precise at 1 m and 3·0 times as precise at 3 m using 3D versus 2D displays (P < 0·001). Participants performed all laparoscopic tasks faster in 3D at both 1 and 3 m (P < 0.001), with mean completion times up to 64 per cent shorter for 3D versus 2D displays. Workload was lower for 3D displays (up to 34 per cent) than for 2D displays at both viewing distances (P < 0·001). Greater viewing distance inhibited performance for two laparoscopic tasks, and increased perceived workload for all three (P < 0·001). Higher stereoacuity was associated with shorter completion times for the navigating in space task performed in 3D at 1 m (r = - 0·40, P = 0·001)., Conclusion: 3D displays offer large improvements over 2D displays in precision of depth judgements, technical performance and perceived workload., (© 2017 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Background: The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement., Objective: The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation., Design: During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts., Setting: The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee., Patients: Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons., Main Outcome Measures: Assessment tool reliability and internal consistency were measured., Results: From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006)., Limitations: The study was limited by rater bias to technique and style., Conclusions: The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Purpose: We aimed to present the factors associated with lymph node harvest (LNH) and seek whether surgical quality control measures can improve LNH., Methods: From a prospectively collected data at a single institution, 874 CRC patients who underwent curative surgery between 2004 and 2013 were included. Factor and survival analyses were performed regarding LNH. Subgroup analysis was performed according to LNH group (LNH ≥ 12 vs LNH < 12) and year of surgery (2004-2008, 2009-2011, and 2012-2013 group)., Results: In the multivariate analysis, tumor location (OR 0.6, p < 0.001), stage (OR 1.95, p < 0.001), and year of surgery (OR 3.86, p < 0.001) showed an association with adequate LNH. In the subgroup analysis categorized by the year of surgery, surgical quality control measures by standardized laparoscopic surgery (OR 52.91, p < 0.001) showed notable association with adequate LNH. Comparing the 2009-2011 and 2012-2013 group, the national quality assessment program additionally improved adequate LNH percentage (83.9 vs 94.3%). In the survival analysis, disease-free survival (DFS) differed according to year of surgery, standardized laparoscopic surgery with high vascular ligation, and adequate LNH by stage. In the overall survival (OS) analysis, the LNH-related factors did not show significant difference., Conclusions: Through standardized laparoscopic surgery with high vascular ligation and national quality assessment program, surgical quality control had a positive impact on the increase of adequate LNH. Improving the modifiable LNH factors resulted in the enhancement of adequate LNH and related DFS.

Background: Postoperative upper gastrointestinal series (UGI) has never been shown to be effective in ruling out leaks or obstruction after gastric bypass or sleeve gastrectomy. In sleeve gastrectomies, UGI will define the shape of the sleeve and rule out a retained fundus that was not optimally excised during surgery., Objectives: We aimed to investigate the impact of a "retained fundus" on weight loss to determine whether UGIs can be used to gauge success of the operation and predict outcome., Setting: Urban community teaching hospital, United States., Methods: Retrospective study analyzing routine UGIs performed on 203 consecutive patients. Exclusion criteria included low quality UGI (absence of a still image of complete fill with contrast), revisions from gastric band to sleeve, absence of weight-loss data, postoperative leak, and postoperative stenosis., Results: A total of 149 patients were included. Mean excess weight loss at one year for groups 1 through 4 was 67.3%, 72.7%, 67.8%, and 65.9%, respectively. There was no significant statistical difference in excess weight loss between the optimal group and the group of both mild and severe retained fundus (P = .22). The weight loss remained equivalent even when comparing the optimal sleeves with only those with severe retained fundus (P = .19). There was a statistically significant difference in quality of sleeve gastrectomies on UGI with surgical experience showing less retained fundus on the UGIs (P = .006) in the latter half of the series., Conclusion: Retained fundus does not seem to cause inferior weight loss in the early postoperative period. Thus, UGI cannot predict weight loss outcomes in the short term., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Aim: Delivery of quality colorectal surgery requires adequate resources. We set out to assess the relationship between resources and outcomes in English colorectal units., Method: Data were extracted from the Association of Coloproctology of Great Britain and Ireland resource questionnaire to profile resources. This was correlated with Hospital Episode Statistics outcome data including 90-day mortality and readmissions. Patient satisfaction measures were extracted from the Cancer Experience Patient Survey and compared at unit level. Centres were divided by workload into low, middle and top tertile., Results: Completed questionnaires were received from 75 centres in England. Service resources were similar between low and top tertiles in access to Confidential Enquiry into Patient Outcome and Death (CEPOD) theatre, level two or three beds per 250 000 population or the likelihood of having a dedicated colorectal ward. There was no difference in staffing levels per 250 000 unit of population. Each 10% increase in the proportion of cases attempted laparoscopically was associated with reduced 90-day unplanned readmission (relative risk 0.94, 95% CI 0.91-0.97, P < 0.001). The presence of a dedicated colorectal ward (relative risk 0.85, 95% CI 0.73-0.99, P = 0.040) was also associated with a significant reduction in unplanned readmissions. There was no association between staffing or service factors and patient satisfaction., Conclusion: Resource levels do not vary based on unit of population. There is benefit associated with increased use of laparoscopy and a dedicated surgical ward. Alternative measures to assess the relationship between resources and outcome, such as failure to rescue, should be explored in UK practice., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: There are three minimally invasive methods for the management of large upper impacted ureteral stones: mini-percutaneous nephrolithotomy (MPCNL), transurethral ureteroscope lithotripsy (URSL), and retroperitoneal laparoscopic ureterolithotomy (RPLU). This study aimed to compare MPCNL, URSL, and RPLU, and to evaluate which one is the best choice for large upper impacted ureteral stones., Methods: Between January 2012 and December 2015, at the Department of Urology, Huai'an First People's Hospital, 150 consecutively enrolled patients with a large upper impacted ureteral stone (>15 mm) were included. The patients were randomly divided (1:1:1) into the MPCNL, URSL, and RPLU groups. The primary endpoint was success of stone removal measured 1 month postoperatively and the secondary endpoints were intraoperative and postoperative parameters and complications., Results: Fifteen patients needed auxiliary ESWL after URSL, and 3 patients after MPCNL, but none after RPLU. The stone clearance rate was 96% (48/50) in the MPCNL group and 72% (33/46) in the URSL group. In the RPLU group the stones were completely removed and the stone clearance rate was 100% (48/48) (P = 0.021 vs. URSL; P = 0.083 vs. MPCNL). Operation-related complications were similar among the three groups (all P > 0.05). Hospital stay was shorter in the URSL group compared with MPCNL (P = 0.003). Operation time was the shortest with URSL and the longest with MPCNL (all P < 0.05)., Conclusions: MPCNL and RPUL are more suitable for upper ureteral impacted stones of >15 mm. URSL could be considered if the patient is not suitable for general anesthesia, or the patient requests transurethral uretroscopic surgery., Trial Registration: This study was registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR-INR-17011507 ; Registration date: 2017-5-22).

The aim of this study was to describe and validate a homemade laparoscopic trainer. The abdominal cavity is simulated within a 3-mm-thick stainless steel model. Thirty-four participants were evaluated in a pilot study to validate our model. Participants were divided into experts (n = 19) and novices (n = 15) to perform basic and complex laparoscopic skills. The comparison between the homemade trainer (HT) and the standard laparoscopic trainer showed no significant differences for the 2 tasks performed for each group ( P > .05). The experts' performance of the 2 tasks was statistically different from the novices ( P < .05) on both trainers. Both experts (84%) and novices (87%) approved the HT as an effective home trainer. Our HT seems to fulfill the conditions of performing the basic and complex laparoscopic psychomotor skills at a low cost and similar efficiency.

Summary: Laparoscopic donor nephrectomy (LDN) is the gold standard for kidney donation. Recent literature has led to considerable debate regarding the safest route to provide vascular control during this procedure. The most common devices used for vascular control during LDN are staplers and surgical clips. Opinions regarding the safety of these devices vary, as both are prone to dysfunction. Certain clips have already been contraindicated for use on the donor artery owing to reports of catastrophic complications of falling off. Donor safety is paramount to the continued success of renal transplantation in Canada. A review of existing practice at each institution may be called for to ensure the safest standards possible are in place. An appendix to this commentary is available at canjsurg.ca.

Introduction: Virtual reality simulation is a topic of discussion as a complementary tool to traditional laparoscopic surgical training in the operating room. However, it is unclear whether virtual reality training can have an impact on the surgical performance of advanced laparoscopic procedures. Our objective was to assess the ability of the virtual reality simulator LAP Mentor to identify and quantify changes in surgical performance indicators, after LAP Mentor training for digestive anastomosis., Material and Methods: Twelve surgeons from Centro Hospitalar de São João in Porto (Portugal) performed two sessions of advanced task 5: anastomosis in LAP Mentor, before and after completing the tutorial, and were evaluated on 34 surgical performance indicators., Results: The results show that six surgical performance indicators significantly changed after LAP Mentor training. The surgeons performed the task significantly faster as the median 'total time' significantly reduced (p < 0.05) from 759.5 to 523.5 seconds. Significant decreases (p < 0.05) were also found in median 'total needle loading time' (303.3 to 107.8 seconds), 'average needle loading time' (38.5 to 31.0 seconds), 'number of passages in which the needle passed precisely through the entrance dots' (2.5 to 1.0), 'time the needle was held outside the visible field' (20.9 to 2.4 seconds), and 'total time the needle-holders' ends are kept outside the predefined operative field' (88.2 to 49.6 seconds)., Discussion: This study raises the possibility of using virtual reality training simulation as a benchmark tool to assess the surgical performance of Portuguese surgeons., Conclusion: LAP Mentor is able to identify variations in surgical performance indicators of digestive anastomosis.

Objective: To evaluate the feasibility and safety of applying enhanced recovery after surgery (ERAS) protocol in patients undergoing laparoscopic distal pancreatectomy. Methods: Data of 36 patients undergoing laparoscopic distal pancreatectomy from May 2016 to May 2017 in the First Affiliated Hospital, Zhejiang University School of Medicine were reviewed. The patients were divided into ERAS group ( n =12) and control group ( n =24). The patients in ERAS group received a series of enhanced recovery procedures, including multimodal analgesia, early off-bed activity and early oral food-taking, etc. Operation time, intraoperative blood loss, time to first flatus, postoperative complications, and length of postoperative hospital stay were evaluated. Results: There were no statistically significant differences in operation time and intraoperative blood loss between ERAS group and control group (all P >0.05). The time to first flatus and length of postoperative hospital stay were significantly shortened in ERAS group (all P <0.05). The ERAS group had lower incidence of postoperative complications (41.7% vs. 66.7%), and the complications in ERAS group tended to be milder, but the differences failed to show statistical significance (all P >0.05). Conclusion: The ERAS protocol for laparoscopic distal pancreatectomy can significantly promote gastrointestinal function recovery and shorten postoperative hospital stay, and may reduce the incidence of postoperative complications.