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Background: Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB)., Objective: This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU)., Methods: PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee., Results: Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures., Conclusions: This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. All rights reserved.)

Background: In recent years, there has been growing interest in laparoscopic liver resection (LLR) and the audit of the results of surgical procedures. The aim of this study was to define reference values for LLR in segments 7 and 8., Study Design: Data on LLR in segments 7 and 8 between January 2000 and December 2020 were collected from 19 expert centers. Reference cases were defined as no previous hepatectomy, American Society of Anesthesiologists score less than 3, BMI less than 35 kg/m 2 , no chronic kidney disease, no cirrhosis and portal hypertension, no COPD (forced expiratory volume 1 <80%), and no cardiac disease. Reference values were obtained from the 75th percentile of the medians of all reference centers., Results: Of 585 patients, 461 (78.8%) met the reference criteria. The overall complication rate was 27.5% (6% were Clavien-Dindo 3a or more) with a mean Comprehensive Complication Index of 7.5 ± 16.5. At 90-day follow-up, the reference values for overall complication were 31%, Clavien-Dindo 3a or more was 7.4%, conversion was 4.4%, hospital stay was less than 6 days, and readmission rate was <8.33%. Patients from Eastern centers categorized as low risk had a lower rate of overall complication (20.9% vs 31.2%, p = 0.01) with similar Clavien-Dindo 3a or more (5.5% and 4.8%, p = 0.83) compared with patients from Western centers, respectively., Conclusions: This study shows the need to establish standards for the postoperative outcomes in LLR based on the complexity of the resection and the location of the lesions., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pelvic organ prolapse (POP) is a common condition that can affect up to 30% of women over the age of 50. For a long time, open abdominal and laparoscopic sacrocolpopexy (LSCP) have been considered the gold standard in the treatment of apical pelvic organ prolapse (POP). Promontory dissection may expose patients to potential life-threatening intraoperative vascular injuries, as well as damage to sacral roots or the hypogastric nerve. Laparoscopic lateral suspension could be considered as an alternative to LSCP in the treatment of POP due to its favorable objective and subjective outcomes. The aim of this article is to demonstrate a step-by-step approach to laparoscopic lateral suspension for POP with the goal of standardizing this procedure. Technical key points and the latest progress are summarized to provide a reference for subsequent gynecological and urological surgeons., Method: According to our surgical experience of our hospital, demonstrate a step-by-step approach and highlight technical key points for laparoscopic lateral suspension for POP with the aim of standardizing this procedure., Conclusion: LLS with mesh is a safe alternative to laparoscopic sacropexy and is very well suited for uterine-preserving POP surgery. Nevertheless, this novel procedure lacks standardization. Standardization of procedures is necessary to reduce failure rates, generate impactful research data, and enhance patient safety. This article contributes to the standardization of this procedure, and we believe our article will be useful in assisting future gynecological and urological surgeons in performing this procedure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations., (© 2024. The Author(s).)

Introduction: Computerized simulation (CS) of surgery in virtual reality (VR), augmented reality (AR) and mixed reality (MR) settings are used to teach foundational skills, but its applicability in advanced training is to be determined. This review aims to summarize the types of CS available for laparoscopic colorectal surgery (CRS) and its utility in assessment of proficiency., Methods: A systematic review of CS in laparoscopic CRS was done on PubMed, Embase, Scopus and Cochrane Library databases., Results: Eleven relevant observational studies were identified. The most common procedure simulated was laparoscopic colectomy. Assessment using performance metrics measured by the simulator such as path length moved by laparoscopic tools, procedure time and number of discrete movements had the most consistent differentiating ability between expert and non-expert cohorts. Surgeons fared similarly in proficiency scores in assessment with CS compared to assessment with traditional cadaveric or porcine models., Conclusion: CS of laparoscopic CRS may be used in assessment of proficiency using performance metrics measuring economy of movement. CS may be a viable assessment tool in advanced surgical training, but further studies should assess utility of incorporating it as a formal assessment tool in training programs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Robotic platform has been increasingly applied in major hepatectomy. However, the role or advantage of robotic approach comparing with laparoscopic approach in major hepatectomy remains controversial. This meta-analysis compares perioperative outcomes of robotic major hepatectomy (RMH) to laparoscopic major hepatectomy (LMH) for hepatic neoplasms., Methods: PubMed, Web of Science, EMBASE, and Cochrane Library were searched to identify comparative studies compared RMH versus LMH for hepatic neoplasms. The search timeframe was set before May 2023. Main outcomes were mortality, overall morbidities, serious complications, and conversion to open surgery. Secondary outcomes were operative time, intraoperative blood loss, blood transfusion, postoperative length of hospital stay, R0 resection, reoperation, and readmission. Studies were evaluated for quality by Cochrane risk of bias tool or Newcastle-Ottawa scale. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42023410951)., Results: Twelve retrospective cohort studies concerning total 1657 patients (796 RMH, 861 LMH) were included. Meta-analyses showed no significant differences in mortality (OR=1.23, 95% CI=0.50-2.98, P =0.65), overall postoperative complications (OR=0.83, 95% CI=0.65-1.06, P =0.14), operative time (MD=6.47, 95% CI=-14.72 to 27.65, P =0.55), blood transfusion (OR=0.77, 95% CI=0.55-1.08, P =0.13), R0 resection (OR=1.45, 95% CI=0.91-2.31, P =0.12), reoperation (OR=0.76, 95% CI=0.31-1.88, P =0.56), and readmission (OR=0.63, 95% CI=0.28-1.44, P =0.27) between RMH and LMH. Incidence of serious complications (OR=0.60, 95% CI=0.40-0.90, P =0.01), conversion to open surgery (OR=0.41, 95% CI=0.27-0.63, P <0.0001), blood loss (MD=-91.42, 95% CI=-142.18 to -40.66, P =0.0004), and postoperative hospital stay (MD=-0.64, 95% CI=-0.78 to -0.49, P <0.00001) were reduced for RMH versus LMH., Conclusions: RMH is associated with comparable short-term surgical outcomes and oncologic adequacy compared to LMH when performed by experienced surgeons at large centres. RMH may result in reduced major morbidities, conversion rate, blood loss, and hospital stay, but these results were volatile. Further randomized studies should address the potential advantages of RMH over LMH., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: The selection of the most informative quality of care indicator for laparoscopic liver surgery (LLS) is still debated; among those proposed, textbook outcome (TO) seems to provide a compositive measure of the outcomes of surgery. The aim of this study was to investigate the factors related with the TO in a cohort of patients who underwent LLS., Methods: Patients who underwent LLS from 2014 to 2021 were included. TO for LLS (TOLLS) was defined as: R0 resection, absence of intraoperative incidents, severe complications, reintervention, 30-day readmission and in-hospital mortality. When also considering no prolonged length of hospital stay (LOS), the outcome was called TOLLS+., Results: Four hundred twenty-one patients were included; TOLLS was achieved in 80.5%, TOLLS+ in 60.8% cases. R0 resection was obtained in 90.2% cases, intraoperative incidents occurred in 7.8%, severe complications in 5.0%, reintervention in 0.7%, readmission in 1.4% and in-hospital mortality in 0.2%. 32.5% of patients showed prolonged LOS. After univariate and multivariate analysis, factors influencing TOLLS were age (OR 0.967; p=0.003), concomitant surgery (OR 0.380; p=0.003), operative time (OR 0.996; p=0.008) and blood loss (OR 0.241; p<0.001); factors influencing TOLLS+ were ASA-score (OR 0.533; p=0.008), tumour histology (OR 0.421; p=0.021), concomitant surgery (OR 0.293; p<0.001), operative time (OR 0.997; p=0.016) and blood loss (OR 0.361; p=0.003)., Conclusions: TOLLS can be achieved in most patients undergoing LLR, and it seems to be influenced mostly by surgery-related factors; conversely, TOLLS+ is achieved less frequently and seems to be influenced also by patient- and tumour-related factors., (© 2022. The Author(s).)

Background: High-volume and fellowship-trained surgeons have superior outcomes. However, in gynecology, a large proportion of cases are performed by low-volume surgeons. Simulation has been shown to be useful in assessing surgical skill and may be a useful tool in hospital credentialing and maintenance of privileges.Objective: To determine the correlation between a surgical case volume and fellowship training with performance on simulated procedural tasks.Study Design: A total of 108 obstetricians and gynecologists with laparoscopic privileges at 2 academic institutions completed a pre-test survey and performed 3 tasks on the LapSim laparoscopic virtual reality simulator. The pre-test survey inquired about the monthly laparoscopic case volume and prior training. Simulations included a basic skills task (peg transfer) followed by a procedural task (salpingectomy) of 2 difficulty levels (low and moderate). Spearman correlation and Wilcoxon tests were used to determine correlations between the survey responses and performance metrics.Results: Participants included 67 generalists (62%) and 41 fellowship-trained specialists (38%). There was an observed weak correlation among surgical volume (more than 6 cases per month), time to completion, and the amount of blood loss when performing the low-difficulty level salpingectomy (r=-0.32, P=.0007 and r=-0.29, P=.002, respectively). The economy of movement (instrument path length) was correlated to high surgical volume (r=-0.35, P=.0002). Compared with generalists, surgeons with fellowship training performed tasks faster (410.8 seconds [interquartile range, 309.7-595.2]) vs 530.2 seconds (interquartile range, 406.2-605.0; P=.0009), more efficiently at 6.1 m (interquartile range, 4.8-7.3) vs 8.1 m (interquartile range, 5.8-10.7; P=.0003), and with less blood loss at 21.7 mL (interquartile range, 11.8-37.7) vs 42.9 mL (interquartile range, 18.1-70.6; P=.002). Regarding the case volume and fellowship background, there was no difference in ovarian diathermy damage. In addition, there was no difference among most performance parameters for the peg transfer task and the moderate-difficulty salpingectomy procedure.Conclusion: Surgical experience obtained through higher case volume and fellowship training correlate with higher performance scores during simulated procedural tasks. In a previous study, we found a similar correlation with simulated basic skills tasks. The current study is a continuation of an ongoing quality initiative to establish a summative assessment of laparoscopic surgical skills using virtual reality simulator for the maintenance of credentials among obstetrical and gynecologic surgeons. Future studies will compare the performance metrics from laparoscopic procedures performed on virtual reality simulator with the performance in the operating room and clinical outcomes. [ABSTRACT FROM AUTHOR]

Survival analysis following oncological treatments require specific analysis techniques to account for data considerations, such as failure to observe the time of event, patient withdrawal, loss to follow-up, and differential follow up. These techniques can include Kaplan-Meier and Cox proportional hazard analyses. However, studies do not always report overall survival (OS), disease-free survival (DFS), or cancer recurrence using hazard ratios, making the synthesis of such oncologic outcomes difficult. We propose a hierarchical utilization of methods to extract or estimate the hazard ratio to standardize time-to-event outcomes so that study inclusion into meta-analyses can be maximized. We also provide proof-of concept results from a statistical analysis that compares OS, DFS, and cancer recurrence for robotic surgery to open and non-robotic minimally invasive surgery. In our example, use of the proposed methodology would allow for the increase in data inclusion from 108 hazard ratios reported to 240 hazard ratios reported or estimated, resulting in an increase of 122%. While there are publications summarizing the motivation for these analyses, and comprehensive papers describing strategies to obtain estimates from published time-dependent analyses, we are not aware of a manuscript that describes a prospective framework for an analysis of this scale focusing on the inclusion of a maximum number of publications reporting on long-term oncologic outcomes incorporating various presentations of statistical data., Competing Interests: “All authors are employees of Intuitive Surgical, Inc. (AEH, USK, AY, DG, YLi, SL, YLiu) or consult for Intuitive Surgical, Inc. (ABS, SM, AES). There are no patents, products in development or marketed products to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.”

Purpose: The Endoscopic Surgical Skill Quantification System for qualified surgeons (QSs) was introduced in Japan to improve surgical outcomes. This study reviewed the surgical outcomes after initial experience performing laparoscopic distal gastrectomy (LDG) and evaluated the improvement in surgical outcomes following accreditation as a QS., Methods: Eighty-seven consecutive patients who underwent LDG for gastric cancer by a single surgeon were enrolled in this study. The cumulative sum method was used to analyze the learning curve for LDG. The surgical outcomes were evaluated according to the two phases of the learning curve (learning period vs. mastery period) and accreditation (non-QS period vs. QS period)., Results: The learning period for LDG was 48 cases. Accreditation was approved at the 67th case. The operation time and estimated blood loss were significantly reduced in the QS period compared to the non-QS period (230 vs. 270 min, p < 0.001; 20.5 vs. 59.8 ml, p = 0.024, respectively). Furthermore, the major complication rate was significantly lower in the QS period than in the non-QS period (0 vs. 10.6%, p = 0.044)., Conclusions: Experience performing approximately 50 cases is required to reach proficiency in LDG. After receiving accreditation as a QS, the surgical outcomes, including the complication rate, were improved., (© 2021. Springer Nature Singapore Pte Ltd.)

Objective: To define "best possible" outcomes for secondary bariatric surgery (BS)., Background: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS., Methods: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years., Results: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation., Conclusion: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS., Competing Interests: Conflict of Interest Statement: Prof. Peterli reports consulting fees from Johnson & Johnson, outside the submitted work. Prof. Bueter reports personal fees from Johnson & Johnson and Medtronic, outside the submitted work. Prof. Himpens reports personal fees from Ethicon, personal fees from Medtronic, outside the submitted work. Dr. Dillemans reports consulting fees from Medtronic and Johnson & Johnson, outside the submitted work. Prof. Lannoo reports an unrestricted grant from Medtronic. The other authors have no commercial associations to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate laparoscopy-assisted fetoscopic laser photocoagulation (FLPC) of placental anastomoses in the treatment of twin-to-twin-transfusion syndrome (TTTS)., Study Design: We performed a retrospective cohort study analyzing pregnancies complicated by TTTS who underwent FLPC in a single university-affiliated tertiary medical-center. Outcomes were compared between patients who received laparoscopy-assisted FLPC (study group) and patients who underwent the conventional FLPC technique (control group). Baseline characteristics, sonographic findings, procedure details, and neonatal outcomes were compared between groups., Results: The cohort included 278 women with 31 in the study group and 247 in the control group. Sonographic parameters, including fetal biometry and TTTS stage, were comparable between study groups. Gestational age at delivery did not differ between the groups (29.22 ± 4.55 weeks in the study group vs. 30.62 ± 4.3 weeks in the control group, p = 0.09). There were no differences in neonatal survival rates at birth and at 30 days between both groups. A subanalysis comparing the laparoscopy-assisted group to only those patients with anterior placenta in the control group, showed a lower rate of incomplete Solomonization in the laparoscopy-assisted study group (3.4% vs. 33%, p = 0.01)., Conclusion: Laparoscopy-assisted FLPC is a reasonable and safe option that may be offered in cases of FLPC where an anterior placenta restricts adequate surgical access., (© 2021 John Wiley & Sons Ltd.)

Objective: Clarify the normal patterns of voiding after minimally invasive hysterectomy. We also aim to identify perioperative factors associated with delayed time to void immediately following hysterectomy., Design: Retrospective cohort study SELECTION: Women undergoing laparoscopic hysterectomy between September 2012 to October 2018 at a single academic university hospital., Results: 450 minimally invasive hysterectomies were included in the final analysis, 274 (60.9%) robotically-assisted, and 176 (39.1%) conventional laparoscopy. The overall median postoperative time-to-void following a retrograde bladder filling of 150 mL normal saline was 179 min. Based on the 50th percentile of the distribution of the time-to-void, two groups were created. Demographic characteristics between the groups were similar, except those who were above the 50th percentile were more likely to be older, have a reported history of previous myomectomy, and had a longer postoperative PACU stay compared to those below or equal to the 50th percentile. The mean time-to-void following conventional laparoscopic hysterectomy was less than that of robotic surgery (187.3 vs 200.5 min) however the difference was not statistically significant (p=.22). The use of hydromorphone intraoperatively and the combination of oxycodone-acetaminophen postoperatively were more likely to be associated with the group of patients above the 50th percentile but there was no significant difference in perioperative utilization of median morphine milliequivalents (MME) between the two groups., Conclusions: Following laparoscopic hysterectomy (either conventional or with robotic-assistance) with a retrograde bladder fill of 150 mL normal saline most patients will void within 4 h after surgery. This is consistent with historic data on normal voiding patterns facilitating safe same day discharge without prolonged time in the PACU., Competing Interests: Declaration of Competing Interest Dr. Moawad is a speaker for Intuitive Surgical. No other authors have any disclosure to report., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

The closure of port-sites wounds, as the ultimate step of surgical laparoscopic procedures, can be allowed by threads, staples, surgical glue or adhesive sutures. We describe a simple and easy skin suturing technique which saves time and provides significant surgical ergonomics., Competing Interests: Declarations of Competing Interest The authors declare no conflict of interest., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: The study seeks to determine surgical factors related to anal exhaust in patients treated with laparoscopic surgery for benign gynecological diseases and to explore measures that effectively promote the rapid recovery of intestinal function in these patients., Methods: From June 2017 to August 2018, 155 patients with benign gynecological diseases who underwent laparoscopic surgery in our hospital were selected as study subjects. Patients were divided into two groups based on anal exhaust time: the ≤ 24-hour group and > 24-hour group. Factors related to the operation were statistically analyzed for all patients. Chi-squared tests and logistic regression were used for univariate and multivariable analyses., Results: Of 155 gynecological patients, 57 (36.8%) underwent laparoscopic ovarian cyst stripping, 48 (30.9%) underwent laparoscopic salpingectomy with/without oophorectomy, and 50 (32.3%) underwent laparoscopic myomectomy. Among all patients, 62 (40.0%) and 93 (60.0%) had anal exhaust within and after 24 h, respectively. Univariate analysis results revealed differences in the operation method (P = 0.040), intraoperative blood loss (P = 0.037), operation duration (P = 0.007), whether an abdominal drainage tube was placed (P = 0.012) and whether warm saline was used (37 °C) for abdominal washing (P = 0.013) between groups. Logistic regression analysis showed that the duration of the operation (P = 0.027) and whether warm saline was used for abdominal washing (P = 0.040) were the main factors affecting anal exhaust time., Conclusion: During laparoscopy for patients with benign gynecological diseases, abdominal washing with warm water is an important factor that promotes early postoperative anal exhaust and is worthy of use in clinical practice., Competing Interests: Declaration of Competing Interest No potential conflicts of interest were disclosed., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another., Methods: To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis., Results: Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928)., Conclusion: Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The study focused on the influence of intelligent algorithm-based magnetic resonance imaging (MRI) on short-term curative effects of laparoscopic radical gastrectomy for gastric cancer. A convolutional neural network- (CNN-) based algorithm was used to segment MRI images of patients with gastric cancer, and 158 subjects admitted at hospital were selected as research subjects and randomly divided into the 3D laparoscopy group and 2D laparoscopy group, with 79 cases in each group. The two groups were compared for operation time, intraoperative blood loss, number of dissected lymph nodes, exhaust time, time to get out of bed, postoperative hospital stay, and postoperative complications. The results showed that the CNN-based algorithm had high accuracy with clear contours. The similarity coefficient (DSC) was 0.89, the sensitivity was 0.93, and the average time to process an image was 1.1 min. The 3D laparoscopic group had shorter operation time (86.3 ± 21.0 min vs. 98 ± 23.3 min) and less intraoperative blood loss (200 ± 27.6 mL vs. 209 ± 29.8 mL) than the 2D laparoscopic group, and the difference was statistically significant ( P < 0.05). The number of dissected lymph nodes was 38.4 ± 8.5 in the 3D group and 36.1 ± 6.0 in the 2D group, showing no statistically significant difference ( P > 0.05). At the same time, no statistically significant difference was noted in postoperative exhaust time, time to get out of bed, postoperative hospital stay, and the incidence of complications ( P > 0.05). It was concluded that the algorithm in this study can accurately segment the target area, providing a basis for the preoperative examination of gastric cancer, and that 3D laparoscopic surgery can shorten the operation time and reduce intraoperative bleeding, while achieving similar short-term curative effects to 2D laparoscopy., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wenkui Mo and Cansong Zhao.)

Background: Objective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training., Methods: Laparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity., Results: In total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9-3.8) to 1.8 Newton (interquartile range 1.2-2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2-9,025.9) to 3,545.3 mm (interquartile range 2,842.9-4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8-219.0) to 60.7 seconds (interquartile range 46.0-79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation)., Conclusion: Force-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to compare the clinical efficacy of robotic right colectomy (RRC) and laparoscopic right colectomy (LRC) in the treatment of right colon tumor., Methods: We systematically searched PubMed, Web of science, EMBASE ClinicalTrials.gov and Cochrane Central Register for studies (studies published between January 2011 and June 2020). The included studies compared the clinical efficacy of RRC and LRC in the treatment of right colon tumor, and analyzed the perioperative data., Results: Our meta-analysis included 10 studies involving 1180 patients who underwent 2 surgical procedures, RRC and LRC. This study showed that compared with LRC, there was no significant difference in first flatus passage (weighted mean difference [WMD]: -0.37, 95% CI: -1.09-0.36, P = .32), hospital length of stay (WMD: -0.23, 95% CI: -0.73-0.28, P = .32), reoperation (OR: 1.66, 95% CI: 0.67-4.10, P = .27), complication (OR: 0.83, 95% CI: 0.60-1.14, P = .25), mortality (OR: 0.45, 95% CI: 0.02-11.22, P = .63), wound infection (OR: 0.65, 95% CI: 0.34-1.25, P = .20), and anastomotic leak (OR: 0.73, 95% CI: 0.33-1.63, P = .44). This study showed that compared with LRC, the lymph nodes retrieved (WMD: 1.47, 95% CI: -0.00-2.94, P = .05) of RRC were similar, with slight advantages, and resulted in longer operative time (WMD: 65.20, 95% CI: 53.40-77.01, P < .00001), less estimated blood loss (WMD: -13.43, 95% CI: -20.65-6.21, P = .0003), and less conversion to open surgery (OR: 0.30, 95% CI: 0.17-0.54, P < .0001)., Conclusions: RRC is equivalent to LRC with respect to first flatus passage, hospital length of stay, reoperation, complication, and results in less conversion to LRC., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: A high level of surgical skill is essential to prevent intraoperative problems. One important aspect of surgical education is surgical skill assessment, with pertinent feedback facilitating efficient skill acquisition by novices., Objectives: To develop a 3-dimensional (3-D) convolutional neural network (CNN) model for automatic surgical skill assessment and to evaluate the performance of the model in classification tasks by using laparoscopic colorectal surgical videos., Design, Setting, and Participants: This prognostic study used surgical videos acquired prior to 2017. In total, 650 laparoscopic colorectal surgical videos were provided for study purposes by the Japan Society for Endoscopic Surgery, and 74 were randomly extracted. Every video had highly reliable scores based on the Endoscopic Surgical Skill Qualification System (ESSQS, range 1-100, with higher scores indicating greater surgical skill) established by the society. Data were analyzed June to December 2020., Main Outcomes and Measures: From the groups with scores less than the difference between the mean and 2 SDs, within the range spanning the mean and 1 SD, and greater than the sum of the mean and 2 SDs, 17, 26, and 31 videos, respectively, were randomly extracted. In total, 1480 video clips with a length of 40 seconds each were extracted for each surgical step (medial mobilization, lateral mobilization, inferior mesenteric artery transection, and mesorectal transection) and separated into 1184 training sets and 296 test sets. Automatic surgical skill classification was performed based on spatiotemporal video analysis using the fully automated 3-D CNN model, and classification accuracies and screening accuracies for the groups with scores less than the mean minus 2 SDs and greater than the mean plus 2 SDs were calculated., Results: The mean (SD) ESSQS score of all 650 intraoperative videos was 66.2 (8.6) points and for the 74 videos used in the study, 67.6 (16.1) points. The proposed 3-D CNN model automatically classified video clips into groups with scores less than the mean minus 2 SDs, within 1 SD of the mean, and greater than the mean plus 2 SDs with a mean (SD) accuracy of 75.0% (6.3%). The highest accuracy was 83.8% for the inferior mesenteric artery transection. The model also screened for the group with scores less than the mean minus 2 SDs with 94.1% sensitivity and 96.5% specificity and for group with greater than the mean plus 2 SDs with 87.1% sensitivity and 86.0% specificity., Conclusions and Relevance: The results of this prognostic study showed that the proposed 3-D CNN model classified laparoscopic colorectal surgical videos with sufficient accuracy to be used for screening groups with scores greater than the mean plus 2 SDs and less than the mean minus 2 SDs. The proposed approach was fully automatic and easy to use for various types of surgery, and no special annotations or kinetics data extraction were required, indicating that this approach warrants further development for application to automatic surgical skill assessment.

Importance: Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR)., Objective: To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis., Design, Setting, and Participants: Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated., Main Outcomes and Measures: Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin., Results: A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate., Conclusions and Relevance: In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

Objective: The objective of this study is to determine the characteristics and frequency of intraoperative safety threats and resilience supports using a human factors measurement tool., Background: Human factors analysis can provide insight into how system elements contribute to intraoperative adverse events. Empiric evidence on safety threats and resilience in surgical practice is lacking., Methods: A cross-sectional study of 24 patients undergoing elective laparoscopic general surgery at a single center in the Netherlands from May to November, 2017 was conducted. Video, audio, and patient physiologic data from all included procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded safety threats and resilience supports. The codes were categorized into 1 of 6 categories (person, task, tools and technology, physical environment, organization, and external environment)., Results: A median of 14 safety threats [interquartile range (IQR) 11-16] and 12 resilience supports (IQR 11-16) were identified per case. Most safety threat codes (median 9, IQR 7-12) and resilience support codes (median 10, IQR 7-12) were classified in the person category. The organization category contained a median of 2 (IQR 1-2) safety threat codes and 2 (IQR 2-3) resilience support codes per case. The tools and technology category contributed a small number of safety threats (median 1 per case, IQR 0-1), but rarely provided resilience support., Conclusions: Through a detailed human factors analysis of elective laparoscopic general surgery cases, this study provided a quantitative analysis of the existing safety threats and resilience supports in a modern endoscopic operating room., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Reestablishing continuity after the Hartmann procedure, the Hartmann reversal has been recognized as a complex procedure with a high morbidity rate. Laparoscopic reversal of the Hartmann procedure (LHR) is technically challenging, although good short-term results have been reported. We formulated this technique in 2013 and have been gradually devising and standardizing it., Material and Surgical Technique: Ten patients who had undergone the Hartmann procedure from January 2013 to December 2019 and subsequently LHR were retrospectively examined. During the procedure, a circular incision was made at the original site of the colostomy to safely reach the abdominal cavity, and pneumoperitoneum was performed using the glove technique. Next, pelvic adhesions and the descending colon were dissected. If the rectal stump was difficult to identify, an intraoperative endoscope was used. Finally, either a Gambee or stapled anastomosis without tension was performed. The median surgical time was 265 minutes (range, 160-435 minutes), and the median blood loss was 100 mL (range, 10-700 mL). The median postoperative hospital stay was 11 days (range, 8-14 days). In one case, laparotomy was performed because of severe intra-abdominal adhesion., Discussion: No major complication was observed during or after surgery. Therefore, LHR can be performed safely. Standardizing this procedure could render it minimally invasive, although a high level of evidence is needed., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Introduction: The present study assessed the utility of a dry box time trial during laparoscopic surgical training to improve laparoscopic surgical skills and surgical outcomes., Methods: In a monthly time trial, surgeon trainees twice completed a set task that involved grasping a suture, aligning a needle with a needle holder, passing the suture, making three knots, and cutting the two tails of the suture. The mean suturing time was then analyzed. To assess the utility of this time trial, we analyzed the short-term outcomes of patients with stage I to III colon cancer who had undergone laparoscopic colectomy before and after the introduction of the time trial., Results: The monthly time trial was introduced in October 2018, and 52 surgeon trainees participated in the trials examined in this study. Within 6 months of the program's introduction, the mean suturing time had significantly declined to less than 70% of the time trial, while the standard deviations had declined to less than 30%. In comparisons of the short-term outcomes of laparoscopic colon cancer surgery before (n = 49) and after (n = 46) the introduction of the time trial, the operative time tended to decline (P = .074) after the introduction of the time trial, and blood loss was significantly reduced (P = .018). The rate of postoperative complications was similar before and after the introduction., Conclusion: Regular time trials of laparoscopic surgical suture training using a dry box can be useful for improving laparoscopic surgical skills and surgical outcomes. Moreover, time trials can keep trainees motivated., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background: There is growing interest in identifying trainees with surgical aptitude predictive of eventual technical proficiency. Musical tasks involve complex, cerebral activity, and ambidextrousity, which may have a positive impact on the acquisition of surgical skill sets. The purpose of this study was to investigate the influence of prior musical experience on the performance of basic surgical skills., Methods: This was a prospective cross-sectional study involving 51 novice undergraduate and medical school trainees with no prior surgical exposure. Musicality was assessed with a detailed survey and objectively with the Mini-Profile of Music Perception Skills test. Dexterity was assessed using the Purdue Pegboard test. Surgical skills were then evaluated by performing 2 timed suturing trials after observing tutorial video, followed by a timed laparoscopic peg transfer test. Outcomes included both speed and quality of performance., Results: Participants with prior musical experience performed better than nonmusicians on the Mini-Profile of Music Perception Skills test (P = .015), dominant hand dexterity (P = .05), suture quality (P < .03), and laparoscopic peg transfer speed (P < .01). There was no significant difference in the suturing speed between musicians and nonmusicians. The dexterity and Mini-Profile of Music Perception Skills scores were predictive of suture quality (P < .01). Among musicians, duration of musical training, inactivity, instrument type, and certification levels did not correlate with differences in surgical task performance., Conclusion: Musical background is associated with better performance of fundamental surgical skills among surgical novices, particularly technique quality. Although this does not imply superior ultimate surgical ability, musicality may be a marker for basic surgical skill development useful in identifying suitable candidates for surgical training., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes., Objective: This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy., Study Design: This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions., Results: Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72)., Conclusion: Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Minimally invasive radical hysterectomy has been shown to be associated with poorer outcome in an influential prospective, randomized trial. However, many centers worldwide performing minimally invasive radical hysterectomy have data and experience that prove otherwise. We aim to review surgical and oncologic outcomes of patients operated by Laparoscopic Radical Hysterectomy in a tertiary hospital, by experienced surgeons and standardization in radicality, for cervical carcinoma Stage 1A1-1B1 from January 2009 to May 2014., Materials & Methods: Standardised surgical technique with Parametrium & Paracolpium resection approach was adopted by qualified and experienced Gynecologic/Gyne-Oncologic Endoscopic & Minimally Invasive Surgeons in performing Laparoscopic Radical Hysterectomy for Cervical Cancer stage 1A1-1B1 from January 2009-May 2014, involving 53 patients. Electronic Medical Record system (EMR) Of Chang Gung Memorial Hospital(Tertiary Referral Centre), Department of Obstetrics & Gynecology was accessed for surgical and oncologic outcomes., Results: Fifty-Three patients operated from January 2009 to May 2014 were followed up for an average of 96.7 months with longest follow-up at 127 months. There were no cases of recurrence or death reported. 5 Year - Survival Rate and 5 Year Disease-Free Survival Rate were 100%. Two patients received post-operative pelvic radiation concurrent with chemotherapy using Cisplatin due to greater than 1/3 cervical stromal invasion., Conclusion: It is vital to standardize minimally invasive surgical techniques for early stage cervical cancer, with focus on adequate radicality and resection which may contribute to excellent survival outcomes. Further international multi-center randomized trial (Minimally Invasive Therapy Versus Open Radical Hysterectomy In Cervical Cancer) will provide justification for continued practice of MIS in early stage cervical cancer., Competing Interests: Declaration of competing interest Drs. Chyi-Long LEE, Kuan-Gen HUANG, Peng Teng CHUA, Marie Christine Valerie R. MENDOZA, Siew Yen LAI has no Conflict of interest or funding/financial ties to disclose. Ms. Pei San LEE has no Conflict of interest or funding/financial ties to disclose., (Copyright © 2021. Published by Elsevier B.V.)

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another., Competing Interests: Disclosure None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP., Methods: 100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed., Results: 100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m 2 underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis ( P  < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility., Conclusions: Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious., Competing Interests: Conflicts of Interest: Alexander Rosemurgy and Sharona Ross have educational and research relationships with Intuitive Surgical Inc. (Intuitive Corporation, Sunnyvale, CA). Kenneth Luberice, Kaitlyn Crespo, Christina De La Cruz, John-Kevin Dolce, and Iswanto Sucandy have no disclosures/conflicts of interest., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Background: Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers., Method: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology., Results: Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion., Conclusions: The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

Introduction: There has been a constant increase in the number of published surgical videos with preference for open-access sources, but the proportion of videos undergoing peer-review prior to publication has markedly decreased, raising questions over quality of the educational content presented. The aim of this study was the development and validation of a standard framework for the appraisal of surgical videos submitted for presentation and publication, the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool., Methods: An international committee identified items for inclusion in the LAP-VEGaS video assessment tool and finalised the marking score utilising Delphi methodology. The tool was finally validated by anonymous evaluation of selected videos by a group of validators not involved in the tool development., Results: 9 items were included in the LAP-VEGaS video assessment tool, with every item scoring from 0 (item not presented in the video) to 2 (item extensively presented in the video), with a total marking score ranging from 0 to 18. The LAP-VEGaS video assessment tool resulted highly accurate in identifying and selecting videos for acceptance for conference presentation and publication, with high level of internal consistency and generalisability., Conclusions: We propose that peer review in adherence to the LAP-VEGaS video assessment tool could enhance the overall quality of published video outputs.

Study Objective: To demonstrate different techniques, and detail the considerations for obtaining primary laparoscopic access in gynecologic surgery., Design: Video demonstration of the techniques with narrated discussion of each method., Setting: The methods for primary entry in laparoscopy vary by location and technique [1,2]. There are inherent risks with any mode of primary entry, and the risks are also specific to each technique [3-6]. The choice for primary entry depends on the patient's anatomy, surgical history, pathology, and surgeon preference [1,2]., Interventions: This video reviews considerations for choosing the safest entry point and tips for proper entry technique [4,7-10]. The entry sites reviewed include the umbilicus, left upper quadrant, right upper quadrant, and supraumbilical [11]. The entry technique can be either open (Hasson), closed (Veress), or by direct laparoscopic visualization [9,10,12-14]., Conclusion: No single laparoscopic entry technique is superior [3]. The safest and most successful entry method will vary by case characteristics and surgeon training., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery., Target Population: All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications., Options: The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars., Outcomes: Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery., Evidence: We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A)., Intended Audience: Surgeons performing laparoscopic gynaecological surgery., Summary Statements: RECOMMENDATIONS., (Copyright © 2021 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To conduct a systematic review of the literature on the hysteroscopic and laparoscopic repair of isthmocele., Data Sources: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668)., Methods of Study Selection: Studies from the last 20 years that addressed isthmocele repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than 10 women were included., Tabulation, Integration, and Results: The initial search identified 666 articles (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart) (see Supplemental Fig.). We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not in the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both Tables 1 and 2).For abnormal uterine bleeding, hysteroscopic remodeling relived symptoms in 60% to 100% of cases and laparoscopy in 78% to 94%. Secondary infertility was not evaluated in all studies. After hysteroscopic and laparoscopic treatment, 46% to 100% and 37.5% to 90% of those who wished to conceive became pregnant, after the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had fewer than 10 women. However, between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution., Conclusion: Patients with an isthmocele or cesarean scar defect are usually asymptomatic. For symptomatic women, a repair is a valid option. For those with residual myometrial thickness >2 to 3 mm, hysteroscopic remodeling is the modality of choice with an improvement in abnormal uterine bleeding, secondary infertility, and pain. Women with a residual myometrial thickness <2- to 3-mm laparoscopic repair with simultaneous hysteroscopic guidance show similar results. Because available data are limited, no cutoff for the correct choice between hysteroscopy and laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown., (Copyright © 2020. Published by Elsevier Inc.)

The second-generation laryngeal mask airway (LMA) provides a higher sealing pressure than classical LMA and can insert the gastric drainage tube. We investigated the difference in respiratory variables according to the use of second-generation LMA and endotracheal tube (ETT) in laparoscopic living liver donor hepatectomy (LLDH). In this single-blind randomized controlled trial, intraoperative arterial carbon dioxide partial pressure at 2 h after the airway devices insertion (P a CO 2&#95; 2h) was compared as a primary outcome. Participants were randomly assigned to the following groups: Group LMA (n = 45, used Protector LMA), or Group ETT (n = 43, used cuffed ETT). Intraoperative hemodynamic and respiratory variables including mean blood pressure (MBP), heart rate (HR), and peak inspiratory pressure (PIP) were compared. Postoperative sore throat, hoarseness, postoperative nausea and vomiting (PONV), and pulmonary aspiration were recorded. The P a CO 2&#95; 2h were equally effective between two groups (mean difference: 0.99 mmHg, P = 0.003; 90% confidence limits: - 0.22, 2.19). The intraoperative change in MBP, HR, and PIP were differed over time between two groups (P < 0.001, P = 0.015, and P = 0.039, respectively). There were no differences of the incidence of postoperative complications at 24 h following LLDH (sore throat and hoarseness: P > 0.99, PONV: P > 0.99, and P = 0.65, respectively). No case showed pulmonary aspiration in both groups. Compared with endotracheal tube, second-generation LMA is equally efficient during LLDH. The second-generation LMA can be considered as the effective airway devices for securing airway in patients undergoing prolonged laparoscopic surgery. Trial Registration This study was registered at the Clinical Trial Registry of Korea ( https://cris.nih.go.kr . CRiS No. KCT0003711).

Introduction: Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation., Materials and Methods: A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre., Results: A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons., Conclusion: Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To qualify surgeons to participate in a randomized trial comparing laparoscopic and open distal D2 gastrectomy for advanced gastric cancer., Summary of Background Data: No studies have sought to qualify surgeons for a randomized trial comparing laparoscopic and open D2 gastrectomy for advanced gastric cancer., Methods: We conducted a multicenter prospective observational study evaluating unedited videos of laparoscopic and open D2 gastrectomy performed by 27 surgeons. Surgeons performed 3 of each laparoscopic and open distal gastrectomies with D2 lymphadenectomy for gastric cancer. Five peers reviewed each unedited video using a video assessment form. Based on experts' review of videos, a separate review committee decided surgeons as "Qualified" or "Not-qualified.", Results: Twelve surgeons (44.4%) were qualified on initial evaluation whereas the other 15 surgeons were not. Another 9 surgeons were finally qualified after re-evaluation. The median score for Qualified was significantly higher than Not-qualified (P < 0.001).Significant differences between Qualified and Not-qualified were noted both in operation type and in all evaluation area of surgical skill, perigastric, and extra-perigastric lymphadenectomy, although the inter-rater variability of the assessment score was low (kappa = 0.285). However, Not-qualified surgeons' scores improved upon re-evaluation of resubmitted videos.When compared laparoscopy with open surgery, median scores were similar between the 2 groups (P = 0.680). However, open gastrectomy scores for surgical skills were significantly higher than for laparoscopic surgery (P = 0.016)., Conclusions: Our surgeon quality control study for gastrectomy represents a milestone in surgical standardization for surgical clinical trials. Our methods could also serve as a system for educating surgeons and assessing surgical proficiency., Competing Interests: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Han reports grants from Ethicon Endo-Surgery during the conduct of the study. Dr Hyung reports receiving research grants from the Medtronic and is the chief executive officer of Hutom and holding its stocks. He provided consultancy services to Ethicon and Verb Surgical outside the submitted work. No other disclosures were reported. All investigators in this study have declared no potential conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pediatric laparoscopy box with sliding tray. Pediatric procedures have the difficulty of being performed in reduced spaces. Training in reduced spaces has proven to be different in complexity compared to adult laparoscopic endotrainers., Aim: To develop and validate a new neonatal/reduced-space endotrainer., Methods: The simulator was tested and assessed by users with different skill levels and experience in laparoscopic pediatric surgery through an 8-item questionnaire. Construct validity was determined by evaluating the performance of each subject on nine exercises., Results: A 10.5 x 10 x 18 cm acrylic simulator was created, with an internal working surface of 9 x 9 cm. An HD camera was incorporated, with a 0-180° range of movement. All exercises of a Basic Laparoscopic Training Program were adapted on a scale of 1:0.5 to fit in. From 49 participants, 42 (85.71%) answered the survey; 80.5% considered that the simulator reproduces similar conditions to procedures performed in children under one year of age; 61.1% thought that the simulator represents a difficulty identical to procedures performed in newborns; 73.7% considered that the neonatal simulator is more complicated than the adult simulator. Experts showed significantly better performance in all proposed exercises., Conclusion: The simulator has a high-quality image and design that allows training with basic tasks. The endotrainer permitted to discriminate between these different skill levels and was well evaluated by users with diverse surgical experience.

Abstract: This study aimed to compare the effectiveness and safety of reduced-port laparoscopic surgery (RPLS) and conventional multi-port laparoscopic (CMPLS) surgery in the treatment of gastric diseases.The PubMed, Embase, Cochrane Library, Web of Science, and Chinese Biomedical Literature databases were systematically searched for randomized controlled trials, cohort studies, and case control studies on the use of RPLS vs conventional multi-port laparoscopic surgery in treating gastric diseases from their inception until March 10, 2019. The evaluated outcomes were the operative time, blood loss, length of hospital stay, number of dissected lymph nodes, postoperative complications, and conversions. All of these were compared using Stata software version 12.0.A total of 18 studies were included, which involved 2938 patients. In studies referring to the comparison between RPLS and CMPLS in treating gastric diseases, the former showed significantly inferior in terms of operative time (P = .011) and number of dissected lymph nodes (P = .031); but superior results in terms of the estimated blood loss (P = .000) and length of hospital stay (P = .001) than the latter did; however, the rates of postoperative complications (P = .830) and conversions (P = .102) were not statistically significant between the 2 groups.RPLS and CMPLS showed comparable effectiveness and safety in the treatment of gastric diseases in our meta-analysis. Based on the current evidence, we believe that RPLS is an efficacious surgical alternative to CMPLS in the management of gastric diseases because of the shorter hospital stay and reduced blood loss. However, large-scale, well-designed, multicenter studies are needed to further confirm the results of this study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Hepatocellular carcinoma (HCC) is one of the most common type of malignant tumors in adults, and is the most common cause of death in people with cirrhosis. Both laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) are radical treatments for small HCC. However, there is no international standard for the treatment of small HCC, and it is still controversial to choose LH or RFA in treating small HCC. We try to carry out a randomized, controlled, prospective study to compare the the short-term and long-term effects and safety of LH versus RFA in the treatment of small HCC., Methods: This study is a single-center, evaluator-blinded, randomized, controlled clinical trial (RCT). The patients will be randomly divided into RFA group and LH group in a 1:1 ratio according to a computer-generated randomization list. Postoperative complications rates, Alpha fetoprotein (AFP), hospital stay, 1, 2, 3-year overall survival (OS) rates, disease-free survival (DFS) rates and all possible adverse events will be recorded. Statistical analyses will be performed with SPSS v22.0 software., Conclusions: The study will compare the the short-term and long-term effects and safety of LH versus RFA in the treatment of small HCC., Osf Registration Number: doi: 10.17605/OSF.IO/HNX2T., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The Bundled Payments for Care Improvement initiative links payments for service beneficiaries during an episode of care (limited to 90 days from index surgery discharge)., Objective: The purpose of this study was to identify drivers of costs/payments for the major bowel Bundled Payments for Care Improvement initiative., Design: Discharges from the Medicare Standard Analytic Files of hospitals participating in the major bowel bundle of the Bundled Payments for Care Improvement initiative were analyzed., Settings: The study was conducted at 4 tertiary care centers., Patients: All patients in diagnostic related groups of 329, 330, or 331 treated at eligible facilities between September 1, 2012, and September 30, 2014, were included., Main Outcome Measures: We calculated all costs/payments for the bundled period, that is, 3 days before surgery, the index hospitalization including surgery, and the 90-day postoperative period. We then determined costs for laparoscopic versus open procedures using International Classification of Diseases, Ninth Revision, procedure codes for each of the diagnostic related groups, as well as in aggregate. Last, we calculated differential impact of cost drivers on overall total episode costs., Results: In the cohort of hospitals participating in the major bowel Bundled Payments for Care Improvement initiative, open procedures ($45,073) cost 1.6 times more than laparoscopic. For the lowest complexity diagnostic related group (331), performance of the procedure with open techniques was the largest total episode cost driver, because use of postdischarge services remained low. In the highest complexity diagnostic related group (329), readmission costs, skilled nursing facilities costs, and home health services costs were the greatest cost drivers after hospital services., Limitations: The analyses are limited by the retrospective nature of the study., Conclusions: These results indicate that efforts to safely perform open procedures with laparoscopic techniques would be most effective in reducing costs for lower complexity diagnostic related groups, whereas efforts to impact readmission and postdischarge service use would be most impactful for the higher complexity diagnostic related groups. See Video Abstract at http://links.lww.com/DCR/B420. ¿CUÁLES SON LOS FACTORES DETERMINANTES DE LOS COSTOS DE LA INICIATIVA DE MEJORA DE LA ATENCIÓN DE PAGOS COMBINADOS PARA EL INTESTINO MAYOR?: La iniciativa de pagos combinados para la mejora de la atención (BPCI) vincula los pagos para los beneficiarios del servicio durante un episodio de atención (limitado a 90 días desde el alta hospitalaria de la cirugía índice).Identificar los factores determinantes de los costos / pagos de la iniciativa BPCI intestinal mayor.Análisis de altas de los Archivos Analíticos Estándar de Medicare de los hospitales que participan en el paquete intestinal principal de la iniciativa BPCI.Todos los pacientes en Grupos Relacionados con el Diagnóstico (GRD) de 329, 330 o 331 tratados en instalaciones elegibles desde el 1 de Septiembre de 2012 hasta el 30 de Septiembre de 2014.Calculamos todos los costos / pagos para el período combinado, es decir, tres días antes de la cirugía, el índice de hospitalización incluida la cirugía y el período posoperatorio de 90 días. Luego, determinamos los costos de los procedimientos laparoscópicos versus abiertos utilizando códigos de procedimiento ICD-9 para cada uno de los GRD, así como en conjunto. Por último, calculamos el impacto diferencial de los generadores de costos sobre los costos totales del episodio.En la cohorte de hospitales que participan en la iniciativa BPCI del intestino principal, los procedimientos abiertos ($ 45.073) cuestan 1,6 veces más que los laparoscópicos. Para el GRD de menor complejidad (331), la realización del procedimiento con técnicas abiertas fue el mayor factor de costo total del episodio, ya que la utilización de los servicios posteriores al alta se mantuvo baja. En el GRD de mayor complejidad (329), los costos de readmisión, los costos de las instalaciones de enfermería especializada y los costos de los servicios de salud en el hogar fueron los mayores factores de costo después de los servicios hospitalarios.Los análisis están limitados por la naturaleza retrospectiva del estudio.Estos resultados indican que los esfuerzos para realizar procedimientos abiertos de manera segura con técnicas laparoscópicas serían más efectivos para reducir los costos de los GRD de menor complejidad, mientras que los esfuerzos para impactar la readmisión y la utilización del servicio posterior al alta serían más impactantes para los GRD de mayor complejidad. See Video Abstract at http://links.lww.com/DCR/B420.

Background: Radiographic triage measures in patients with new advanced ovarian cancer have yielded inconsistent results., Objective: To determine the correlation between surgeon radiology assessment and laparoscopic scoring by disease sites in patients with newly diagnosed advanced stage ovarian cancer., Methods: Fourteen gynecologic oncology surgeons from a single institution performed a blinded review of pre-operative contrast-enhanced CT imaging from patients with advanced stage ovarian cancer. Each of the patients had also undergone laparoscopic scoring assessment, between April 2013 and December 2017, to determine primary resectability using the validated Fagotti scoring method, and assigned a predictive index value score. Surgeons were asked to provide expected predictive index value scores based on their blinded review of the antecedent CT imaging. Linear mixed models were conducted to calculate the correlation between radiologic and laparoscopic score for surgeons individually, and as a group. Once the model was fit, the inter-class correlation and 95% CI were calculated., Results: Radiology review was performed on 20 patients with advanced stage ovarian cancer who underwent laparoscopic scoring assessment. Surgeon faculty rank included assistant professor (n=5), associate professor (p=4), and professor (n=5). The kappa inter-rater agreement was -0.017 (95% CI -0.023 to -0.005), indicating low inter-rater agreement between radiology review and actual laparoscopic score. The inter-class correlation in this model was 0.06 (0.02-0.21), indicating that surgeons do not score the same across all the images. When using a clinical cut-off point for the predictive index value of 8, the probability of agreement between radiology and actual laparoscopic score was 0.56 (95% CI 0.49 to 0.73). Examination of disease site sub-scales showed that the probability of agreement was as follows: peritoneum 0.57 (95% CI 0.51 to 0.62), diaphragm 0.54 (95% CI 0.48 to 0.60), mesentery 0.51 (95% CI 0.45 to 0.57), omentum 0.61 (95% CI 0.55 to 0.67), bowel 0.54 (95% CI 0.44 to 0.64), stomach 0.71 (95% CI 0.65 to 0.76), and liver 0.36 (95% CI 0.31 to 0.42). The number of laparoscopic scoring cases, tumor reductive surgery cases, or faculty rank was not significantly associated with overall or sub-scale agreement., Conclusions: Surgeon radiology review did not correlate highly with actual laparoscopic scoring assessment findings in patients with advanced stage ovarian cancer. Our study highlights the limited accuracy of surgeon radiographic assessment to determine resectability., Competing Interests: Competing interests: The authors have the following conflicts of interest to disclosure. Relevant financial activities outside the supported work; NDF: consultant/advisory board (Tesaro, BMS/Pfizer); SNW: consultant (AstraZeneca, Clovis Oncology, GSK/Tesaro, Novartis, Roche/Genentech, Eisai, Merck, Pfizer, Circulogene), research funding (ArQule, AstraZeneca, Clovis Oncology, GSK/Tesaro, Novartis, Roche/Genentech, Bayer, Cotinga Pharmaceuticals); LAM: research funding (AstraZeneca); AJ: consultant (Gerson and Lehrman Group, Guidepoint, Iovance, Nuprobe, Simcere, Pact Pharma), research funding (AstraZeneca, BMS, Iovance, Aravive, Pfizer, Immatics USA, Eli Lilly); RLC: consultant (AstraZeneca, Clovis Oncology, GSK/Tesaro, Novartis, Roche/Genentech, Eisai, Merck, Pfizer, Novocure, Genmab, Gamamab, Oncosec, Tarveda), research funding (AbbVie, Genmab, Merck, AstraZeneca, Clovis Oncology, Roche/Genentech); AKS: consultant (Merck, Kiyatec), shareholder (Biopath), research funding (M-Trap). The following authors have no disclosures: PB, JAR-H, PS, AS, MO, LC, MB, BMF, JB, BZ, CL., (© IGCS and ESGO 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None

Background: The availability of validated laparoscopic simulators has not resulted in sustainable high-volume training. We investigated whether the validated laparoscopic serious game Underground would increase voluntary training by residents. We hypothesized that by removing intrinsic barriers and extrinsic barriers, residents would spend more time on voluntary training with Underground compared to voluntary training with traditional simulators., Methods: After 1 year, we compared amount of voluntary time spent on playing Underground to time spent on all other laparoscopic training modalities and to time spent on performing laparoscopic procedures in the OR for all surgical residents. These data were compared to resident' time spent on laparoscopic activities over the prior year before the introduction of Underground., Results: From March 2016 until March 2017, 63 residents spent on average 20 min on voluntary serious gaming, 17 min on voluntary simulator training, 2 h and 44 min on mandatory laparoscopic training courses, and 14 h and 49 min on laparoscopic procedures in the OR. Voluntary activities represented 3% of laparoscopic training activities which was similar in the prior year wherein fifty residents spent on average 33 min on voluntary simulator training, 3 h and 28 min on mandatory laparoscopic training courses, and 11 h and 19 min on laparoscopic procedures., Conclusion: Serious gaming has not increased total voluntary training volume. Underground did not mitigate intrinsic and extrinsic barriers to voluntary training. Mandatory, scheduled training courses remain needed. Serious gaming is flexible and affordable and could be an important part of such training courses.

Background: At present, laparoscopy is relatively mature as a minimally invasive technique, but there are few reports on this approach for the radical treatment of hepatic alveolar echinococcosis (AE). In this study, we aimed to evaluate the safety and feasibility of laparoscopic hepatectomy (LH) for AE treatment., Results: A retrospective review of medical records obtained from 13 patients diagnosed with AE between January 2018 and December 2019 and treated with laparoscopic hepatectomy was conducted at the First Affiliated Hospital of Xinjiang Medical University. All patients (n = 13) underwent hepatic resection using laparoscopy and none were transferred to open surgery. The average duration of surgery was 285 min (145-580 min). Intraoperative bleeding was 305 mL (20-2000 mL). The mean duration of postoperative catheterization was 6.9 days (3-21 days), and postoperative hospital stay was 7.2 days (4-14 days). No complication of Clavien-Dindo grade III or above occurred, except for the second patient with acute liver failure post-surgically. No recurrences or deaths were observed at 9-30 months of follow-up., Conclusions: Laparoscopic hepatectomy appears to be safe and effective in selected AE patients. The advantages of this technique for AE treatment need to be further compared with the classical open approach., (© L. Wan et al., published by EDP Sciences, 2021.)

Background: Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique., Methods: From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 - group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups., Results: There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083)., Conclusions: Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.