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Virtual reality (VR) is increasingly used in surgical education, but evidence of its benefits in complex cognitive training compared to conventional 3-dimensional (3D) visualization methods is lacking. The objective of this study is to assess the impact of 3D liver models rendered visible by VR or desktop interfaces (DIs) on residents' performance in clinical decision-making.From September 2020 to April 2021, a single-blinded, crossover randomized educational intervention trial was conducted at two university hospitals in Belgium and Italy. A proficiency-based stepwise curriculum for preoperative liver surgery planning was developed for general surgery residents. After completing the training, residents were randomized in one of two assessment sequences to evaluate ten real clinical scenarios.Among the 50 participants, 46 (23 juniors/23 seniors) completed the training and were randomized. Forty residents (86.96%) achieved proficiency in decision-making. The accuracy of virtual surgical planning using VR was higher than that using DI in both groups A (8.43 ± 1.03 vs 6.86 ± 1.79, p 0.001) and B (8.08 ± 0.9 vs 6.52 ± 1.37, p 0.001).Proficiency-based curricular training for liver surgery planning successfully resulted in the acquisition of complex cognitive skills. VR was superior to DI visualization of 3D models in decision-making.NCT04959630.

To compare different criteria for post-hepatectomy liver failure (PHLF) and evaluate the association between International Study Group of Liver Surgery (ISGLS) PHLF and the Comprehensive Complication Index (CCI) and 90-day mortality.PHLF is a serious complication following hepatic resection. Multiple criteria have been developed to characterize PHLF.Adults who underwent major hepatectomies at twelve international centers (2010-2020) were included. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) Balzan (INR1.7 and bilirubin2.92 mg/dL) or 3) Mullen (peak bilirubin 7 mg/dL). We compared the 90-day mortality and major morbidity predicted by each definition. We then used logistic regression to determine the odds of CCI 40 and 90-day mortality associated with ISGLS grades.Among 1646 included patients, 19 (1.1%) met Balzan, 68 (4.1%) met Mullen, and 444 (27.0%) met ISGLS criteria for PHLF. Of the three definitions, the ISGLS criteria best predicted 90-day mortality (AUC = 0.72; sensitivity 69.4%). Patients with ISGLS grades BC were at increased odds of CCI 40 (grade B OR 4.0; 95% CI: 2.2-7.2; grade C OR 137.0; 95% CI: 59.2-317.4). Patients with ISGLS grade C were at increased odds of 90-day mortality (OR 113.6; 95% CI: 55.6-232.1). Grade A was not associated with CCI 40 or 90-day mortality.In this diverse international cohort of major hepatectomies, ISGLS grade A was not associated with 90-day mortality or high CCI, calling into question the current classification of patients in this group as having clinically significant PHLF.

The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle- income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted.The American College of Surgeons (ACS) Operation Giving Back (OGB), in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within five domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback.One-hundred sixty-six responses were received after three calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development.This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region.

Background Pancreatic duct occlusion (PDO) without anastomosis is a technique proposed to mitigate the clinical consequences of postoperative pancreatic fistulas (POPF) after pancreaticoduodenectomy. The aim of this study was to appraise the morbidity following PDO through a systematic review and meta-analysis. Methods A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of PDO following pancreaticoduodenectomy. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modeling. Meta-regression analyses were performed to examine the impact of moderators on the overall estimates. Results Sixteen studies involving 1000 patients were included. Pooled postoperative mortality was 2.7%. A POPF was reported in 29.7% of the patients. Clinically relevant POPFs occurred in 13.5% of the patients, while intra-abdominal abscess and haemorrhages occurred in 6.7% and 5.5% of the patients, respectively. Re-operation was necessary in 7.6% of the patients. Postoperatively new onset diabetes occurred in 15.8% of patients, more frequently after the use of chemical substances for PDO (p = 0.003). Conclusions PDO is associated with significant morbidity including new onset of post-operative diabetes. The risk of new onset post-operative diabetes is associated with the use of chemical substance for PDO. Further evidence is needed to evaluate the potential benefits of PDO in patients at high risk of POPF.

The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual surgical education. Using SIGN methodology, evidence-based guidelines were developed for utilizing virtual surgical education within the cognitive and curricula, psychomotor, and faculty development domains. Objective To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development domains. Summary background data During the COVID-19 Pandemic, utilizing virtual learning modalities is expanding rapidly. While the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas. Methods The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the Scottish Intercollegiate Guideline Network (SIGN) methodology. We identified PICO-style questions, conducted systematic literature reviews using PubMed, Embase, and ERIC databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using GRADE, NOS-E and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations. Results Eleven PICO-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into three domains: cognition and curricula (n = 92), psychomotor, (n = 119) and faculty development (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel. Conclusion The evidence-based guidelines developed using SIGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation.

The liver is a common site of metastatic cancer spread, and metastatic lesions are the most common malignant liver tumors. Diagnosis of liver metastases often is established based on clinical assessment, laboratory tests, and appropriate imaging. Surgical resection is the treatment of choice for resectable colorectal and neuroendocrine liver metastases. Long-term survival outcome data after treatment of hepatic metastases of noncolorectal non-neuroendocrine tumors are less robust. The treatment strategy for patients with liver metastases should be determined case by case in a multidisciplinary setting.

The objective of the study was to identify and to evaluate the impact of educational interventions to learn and train liver surgery outside the operating room. A systematic literature search was conducted using PubMed, Web of Science, Embase, and ERIC databases from inception to September 2019 according to the PRISMA guidelines. Studies describing and assessing outcomes of educational interventions in liver surgery, outside the operating room, were included. Neither language nor date of publication restriction was applied. Methodological quality was appraised using NOS-E (Newcastle-Ottawa Scale for Education), and the level of evidence was evaluated based on GRADE (Grades of Recommendation Assessment, Development, and Evaluation) standards. Of the 10,403 screened abstracts, 53 articles were eligible for inclusion, comprising 27 descriptive studies (50.9%), 14 case series assessing any relevant outcome (26.4%), 8 non-randomized controlled trials (15.1%), and 4 randomized controlled studies (7.5%). Almost half (26/53) of the studies did not include any participants, while the remainder of the publications (27/53) involved 1306 learners. The majority of the studies focused on cognitive knowledge (31/53) and/or psychomotor skills training (24/53). Only one publication assessed affective skills. The GRADE score was very low or low in most articles (46/53). Five studies were scored high (5-6) according to NOS-E. Two studies reported data regarding the reliability and validity of employed assessment tools. High-quality studies, particularly well-designed randomized controlled trials that evaluate the effectiveness of simulation-based training on learner behavior and patient outcomes in liver surgery, are still lacking. Forthcoming studies should use robust assessment tools supported by validity evidence.

Background Hepatopancreatobiliary (HPB) Fellowship training in the Americas consists of 3 distinctive routes with variable curricula: Surgical Oncology Fellowship via the Society of Surgical Oncology (SSO), Abdominal Transplant Surgery Fellowship via the American Society of Transplant Surgeons (ASTS), and HPB Fellowship via the Americas Hepato-Pancreato-Biliary Association (AHPBA). Our objective was to establish a pan-American consensus among HPB surgeons, surgical oncologists, abdominal transplant surgeons, and general surgery residency program directors (GSPDs) on a core knowledge curriculum for HPB fellowship, and to identify topics appropriate for general surgery residency and subspecialty beyond HPB fellowship. Study Design A 3-round modified Delphi process was used. Baseline statements were developed by the Education and Training Committee of the AHPBA, in collaboration with representatives of the SSO, ASTS, and GSPDs. The expert panel, consisting of members of the 3 societies together with GSPDs, rated the statements on a 5-point Likert scale and suggested editing or adding new statements. A statement was included in the final curriculum when Cronbach’s alpha value was ≥ 0.8 and ≥ 80% of the panel agreed on inclusion. Results The response rate was 100% for the first round, and 98% for the second and third rounds. Eighty-nine of 138 proposed statements were included in the final HPB fellowship curriculum. Curricula for general surgery residency and subspecialty beyond HPB fellowship included 50 and 29 statements, respectively. Conclusions A multinational consensus on core knowledge for an HPB fellowship curriculum was achieved via the modified Delphi method. This core curriculum may be used to standardize HPB fellowship training across different pathways in the Americas.

Stapled transanal rectal resection (STARR) is a new surgical procedure and minimally invasive transanal operation for rectocele and mucosal/rectal prolapse. In this study, we aimed to assess the frequency of post-operation complications in chronically constipated patients. In this cross-sectional study, 17 patients who underwent STARR in Rasool-e-Akram Hospital in Tehran, Iran, during 2012 and 2013 were enrolled. Pre- and post-operation records were evaluated. Post-operation complications were addressed. Visual Analog Scale (VAS) was used to measure pain intensity. Seventeen patients with a mean age of 41.6 ± 8.4 years (12 females and 5 males) were evaluated, and follow-up time was 13.2 ± 3.4 months. Post-operative pain was the most common complication that was observed in five patients (30%). In one patient, pain was seen as an acute complication and in another patient as a chronic complication. Post-operative bleeding was observed in four patients (23%). Statistical comparison of pre- and post-operative showed a significant reduction in some cases with bleeding. (P = 0.016). STARR can be used in management of the chronic obstructive constipation as a safe and acceptable method.

Background In general surgery residency, hepatobiliary training varies significantly across the world. The aim of this study was to establish an international consensus among hepatobiliary surgeons on components of a hepatobiliary curriculum for general surgery residents. Methods A three-round modified Delphi technique was employed. Fifty-two hepatobiliary surgeons involved in general surgery training programs were invited. An initial questionnaire was developed by a group of experts in hepatobiliary and educational research after a systematic literature review. It comprised 90 statements about knowledge, technical skills, attitudes, and postoperative care. Panelists could add or alter items. The survey was delivered electronically and the panel was instructed to score the items based on 5-point Likert scale. Consensus was reached when at least 80% of panelists agreed on a statement with Cronbach's alpha value >0.8. Results Forty-one (79%) experts have participated. Sixteen panelists are based in Asia, 14 in Europe, and 11 in the Americas. Eighty percent of all proposed skills (81/101) were considered fundamental including knowledge (39/43), technical skills (16/32), attitude (15/15), and postoperative care (11/11). Conclusion An international consensus was achieved on components of a hepatobiliary curriculum. Acquiring broad knowledge is fundamental during residency. Advanced liver resection techniques require specialized hepatobiliary training.

Objectives: The purpose of this study was to evaluate the feedback of participants upon laparoscopic liver surgery (LLS) course on Thiel-embalmed human bodies. Methods: From 2010 to 2017, ten LLS masterclasses have been organized by the Department of Hepatobiliary Surgery at Ghent University Hospital. A 23-question anonymous survey was electronically sent to 119 participants between November 2017 and January 2018, exploring their characteristics and asking for evaluation of the course. The obstacles for implementing LLS in their centers have been assessed. Results: Sixty-four surgeons (53.8%) responded to the survey; 42 (65.6%) were employed at a university hospital; and 39 (60.9%) were in the first decade of their practice as a consultant surgeon. Forty-three (67.2%) surgeons reported an increased percentage of LLS cases afterward. Training on Thiel cadavers was considered superior (49.2%) to other training options including proctoring in the operating room (34.9%), virtual reality (6.3%), video training (4.8%) and practicing on pigs (4.8%). Obstacles identified contained inadequate training, patient’s referral pattern, financial issues, lack of dedicated surgical team and time constrains. Conclusions: This survey revealed that a structured short-time program incorporating interactive discussion, live operations and hands-on training on human bodies under proctorship may enhance efficient training in laparoscopic liver surgery. In a step forward for upcoming courses, the importance of team building has to be addressed.

OBJECTIVE: To evaluate the European experience after Adult-to-adult living donor liver transplantation using the left liver (LL-aLDLT). SUMMARY BACKGROUND DATA: LL-aLDLT decreases donor risk but provides a smaller graft that increases recipient risk as compared with right liver (RL-aLDLT). However, there is little knowledge of results obtained after LL-aLDLT in Europe. METHODS: This is a European multicenter retrospective study which aims to analyze donor and recipient outcomes after 46 LL-aLDLT. RESULTS: Seventy-six percent of the grafts were harvested by minimally invasive approach. Mean donor hospital stay was 7.5 ± 3.5 days. Donor liver function was minimally impaired, with 36 donors (78.3%) without any 90-day complication, and 4 (8.7%) presenting major complications. One, 3, and 5-year recipient survival was 90.9%, 82.7%, and 82.7%, respectively. However, graft survival was of 59.4%, 56.9%, and 56.9% at 1, 3, and 5 years respectively, due to a 26.1% urgent liver retransplantation (ReLT) rate, mainly due to SFSS (n = 5) and hepatic artery thrombosis (HAT, n = 5). Risk factor analysis for ReLT and HAT showed an association with a graft to body weight ratio (GBWR) 0.6% was associated with a lower ReLT rate (0% vs. 33%, P = 0.044). CONCLUSIONS: Our analysis showed low donor morbidity and preserved liver function. Recipient outcomes, however, were hampered by a high ReLT rate. A strict selection of both donor and recipients is the key to minimize graft loss.

Surgical resection with negative margins is the standard treatment for perihilar cholangiocarcinoma whenever possible. Patient’s frequent low performance status at presentation and need of extended resections require optimization of the patient’s condition in the preoperative setting. Biliary drainage is mandatory in case of cholangitis, jaundice-related liver insufficiency, malnutrition or renal failure. Drainage is also necessary in case of portal vein embolization (PVE), in order to improve regeneration of the future liver remnant (FLR). Unilateral drainage of the FLR should be obtained, while bilateral drainage is required in case of cholangitis, slow reduction in bilirubin and uncertainty about the side of resection. The technique for biliary drainage should be decided according to the local expertise and other factors (need of further evaluation of tumour extension, patient’s compliance, necessity of bilateral drainage). Preoperative symbiotics-reduce postoperative infections. PVE is safe and increases the safety of surgery in case of extended liver resections. It is indicated in case of low FLR volume (

Necrotizing fasciitis of the upper extremity is reported.Necrotizing fasciitis is a rare, life-threatening infection most commonly seen in patients with diabetes mellitus, intravenous drug abuse, and immunocompromised conditions. The extremities are the primary sites of involvement in as many as two thirds of the cas-es. In a significant proportion of patients, the extremities are involved as a result of trau-ma, needle puncture or extravasation of drugs. The infection is usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation. We present a patient with necrotizing fasciitis of the upper limb and pre-sent our experience with this often lethal condition.

Objective: Although there are various therapeutic modalities to manage patients suffering from sacrococcygeal pilonidal sinus disease, there remains controversy over a standard method to treat such patients. In this study the postoperative outcomes after three different surgical methods of wound repair in patients with sacrococcygeal pilonidal sinus were compared. Method: Patients were divided randomly into three different groups. All of the patients underwent a wide excision of their pilonidal sinus; the subsequent surgical wound was left open in the first group (lay open group) whereas it was repaired with a simple primary closure and a rhomboid flap in the second and third groups. Variables including length of hospitalisation, time for wound healing, time off work, recurrence and surgical complications were evaluated. Results: A total of 60 patients with an average age of 27.61 years were studied, including 47 (78.3%) men and 13 (21.7%) women. Postoperative hospitalisation time was significantly shorter in patients who were treated using the simple primary closure method than those with the rhomboid flaps. However, there were no differences in terms of postoperative hospitalisation time between the lay open and simple primary groups or the lay open and rhomboid groups. The period of absence from work was significantly shorter in patients who were managed by a simple primary closure or rhomboid flap technique comparing to those whose wound was left open (pConclusion: Considering the earlier wound healing period, less days absent from work, lower complication levels and recurrence rates, the simple primary closure or rhomboid flap techniques appear to be better options to treat the subsequent wound after a wide excision of pilonidal sinus when compared to the lay open method. The simple primary closure method causes no cosmetic disfiguration and the most promising option among the three techniques assessed. Declaration of interest: The authors have declared that no conflict of interest exists.

BACKGROUND: In the modern day cities, home treadmill usage is increasing. Toddlers are prone to a special injury by the treadmill, during workout the toddler tries to get on the belt and the roller action pulls the fingers under the belt and get caught between the belt and a metal rod under the machine and the belt scrapes the fingers. If untreated some of these injuries will lead to flexion contracture. The usual treatment is release of contracture and skin grafting, however, graft discoloration and recurrence of contracture are the complications of this method and the patients usually seek treatment for the brown discoloration of the grafts at a later age. OBJECTIVES: In this study we assess the results of Z-plasty in combination with soft tissue distraction without skin grafting with long term usage of splint as an alternative treatment for these patients. MATERIALS AND METHODS: In this retrograde descriptive cross-sectional study, we evaluated the patients presented with treadmill hand injuries between the years 2006 and 2011. Demographic data including age and sex in addition to other information including location of trauma, severity of trauma, time elapsed between the trauma and treatment, type of treatment including wound care and surgical method and treatment outcomes were assessed. RESULTS: A total of 8 patients (3 girls and 5 boys) following finger treadmill injury were assessed. 15 fingers in 7 patients had volar injury. The middle finger was the most commonly injured finger. In all patients a minimum of 2 fingers were injured and in just 1 patient 3 fingers were injured. In long-term follow-up all the patients had acceptable volar skin and complete ROM of the fingers. CONCLUSIONS: Due to discoloration of the skin graft and recurrence of contracture following skin graft as the sole treatment for the injury, application of Z-plasty with soft tissue distraction and long term splints seems to be a proper alternative treatment for these patients.