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Background The adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons’ comfort with oncoplastic techniques and rate of adoption of these techniques in their practice. Material and methods An online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages. Results A total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning. Conclusion A hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.

Objective: Avoiding surgical delay in the operating room (OR) is essential to provide timely, safe, and cost-effective care. The objective of this study was to identify the causes of OR delays and ...

Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME.Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME.Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1–80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15–25 cases] v. 15 cases [IQR 10–20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10–19 cases] v. 9 cases [IQR 5–10 cases]).These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME.Selon des données préliminaires, l’exérèse totale du mésorectum par voie transanale (ou TaTME, pour transanal total mesorectal excision) est une solution de rechange sécuritaire à l’approche abdominale pour le cancer du rectum. Cette étude vise à faire le point sur le traitement du cancer rectal au Canada et à mesurer l’intérêt à l’endroit de la technique TaTME.Des chirurgiens ont été invités à répondre à un sondage sur leur façon de prendre en charge le cancer rectal et sur leur opinion au sujet de la TaTME.Quatre-vingt-quatorze chirurgiens ont répondu au sondage (taux deréponse 38 %). Le nombre de cancer rectaux traités annuellement par chirurgien variait grandement (de 1 à 80 cas, nombre médian 15 cas). Vingt-sept pour cent des participants appliquaient la TaTME au moment du sondage et 43 % de ceux qui ne l’appliquaient pas disait avoir l’intention de s’y initier. Les chirurgiens qui appliquaient la TaTME se disaient d’avis qu’il fallait un volume annuel plus élevé de cas de cancer rectal pour garder la main comparativement aux chirurgiens qui n’appliquaient pas cette technique (nombre médian de 20 cas [éventail interquartile (ÉIQ) 15–25 cas] c. 15 cas [ÉIQ 10–20 cas]). Les chirurgiens qui appliquaient la TaTME ont aussi estimé qu’il fallait un volume annuel plus élevé de cas de TaTME pour garder la main (nombre médian de 12 cas [ÉIQ 10–19 cas] c. 9 cases (ÉIQ 5–10 cas]).Ces observations permettent de mieux définir les pratiques actuelles des chirurgiens qui soignent le cancer rectal au Canada et mettent en lumière les enjeux complexes inhérents à l’apprentissage de la TaTME.

Introduction Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes that jeopardize safety and efficiency. In this study, our objective was to identify and characterize procedural steps, intraoperative distractions, errors, and threats, as well as the non-technical skills of the team during a common minimally invasive gynecologic procedure. Methodology This was a cross-sectional pilot study of 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device (ORBB). Trained analysts reviewed and coded the recordings. Results The median total case time was 165 minutes (interquartile range [IQR]: 160-178 minutes) with the shortest step being cystoscopy and the longest being vaginal cuff closure. Time pressure and device absence or malfunction occurred in 48% of the cases, and a median of 262 (IQR: 228-304) auditory distractions were noted per case. There was a median of 3 (IQR: 2-4) safety threats identified per case and at least one error was identified in 11/25 cases (44%). Only two adverse events were noted among all 25 cases. Observed non-technical skills were mainly positive, and observations were the highest for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. Conclusions This study is a novel application of the ORBB in the gynecology operating room to capture information regarding procedure times, intraoperative distractions, errors, and non-technical skills of the team. Frequent intraoperative cognitive and auditory distractions were noted. Although adverse events were rare, safety threats were identified. Ongoing and future research from our group will aim to identify key areas for organizational, technological, and team improvement to minimize inefficiencies and optimize patient safety in the operating room.

Lynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada. We recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed. Twenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified. This study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.

Background Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. Study design Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. Results Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. Conclusions An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Lynch syndrome (LS), an autosomal dominant cancer syndrome, is the most common cause of hereditary colon cancer. Currently, however, less than 5% of patients with LS have been identified. Reflex-testing programs (in which tumors of patients with colorectal cancer are routinely evaluated for LS) have been proposed for better identification of affected individuals, yet the uptake of these programs within health care systems is limited. This study explored the structure, implementation challenges, and future directions of existing international population-based reflex LS testing programs. The study identified existing reflex-testing LS programs through the current literature and through a qualitative sampling approach. Key informants from each program were interviewed. Qualitative data were analyzed using a grounded theory analytic technique approach. The interviews were completed by 26 informants across seven identified programs. Three key themes were identified: (1) tension between a program imposed on stakeholders (a top-down approach) versus initiation of the program at the stakeholder level (bottom-up approach), (2) identification of pathologists as drivers of program success, and (3) strategies to optimize possible LS patients liaising with genetic counselors. Barriers to successful implementation included lack of stakeholder engagement and concerns regarding cost. Facilitators included strong administration to coordinate patient tracking and flexibility during the implementation process. Existing reflex-testing LS programs have varying structures, standards, and protocols. Program design can have a direct effect on the uptake of genetic testing. These are important considerations in the large-scale planning of LS reflex-testing programs within health systems.

BACKGROUND: YouTube(®) has provided a forum to share surgical videos in the public domain which may be used for education. The quality of surgery and accompanying educational material is unknown. YouTube(®) videos of gastrectomy with D2 lymphadenectomy (D2-LND) for gastric cancer were evaluated for quality and completeness. METHODS: YouTube(®) was searched using the terms “D2 lymphadenectomy” and “Gastric Cancer” for open and laparoscopic videos. The Korean Laparoscopic Gastrointestinal Surgical Society (KLASS) outlined 22 steps that define quality and completeness of D2-LND. These guidelines were used to score D2-LND for each video. Four physician reviewers independently scored each surgical video. Scores were compared using Student’s t-test. RESULTS: Ten laparoscopic and 10 open surgery videos were assessed. Each video was scored for quality and completeness and assigned a score out of 22. Mean score for open D2-LND was 15 (95% CI: 12.54–17.46). Mean score for laparoscopic D2-LND was 15.4 (95% CI: 14.34–16.46; P=0.77). The most consistently performed steps were the dissection of lymph node stations 1, 3, 4 and 5. The most commonly omitted steps were the dissection of lymph node station 6: exposure and identification of the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein. CONCLUSIONS: There is a wide range of quality and completeness of D2-LND videos. On average, D2-LND videos are only two-thirds complete.

Objectives Operating room delays can result from a chain of intra-operative events including technical factors, equipment failures or unavailability, and non-technical human factors. Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes of inefficiencies. Our objective was to measure and characterize procedural steps, intra-operative distractions and delays during a common minimally invasive gynecologic procedure and identify if these delays correlated with team technical and non-technical scores. Methods A cross-sectional study was conducted of 11 patients undergoing total laparoscopic hysterectomy (TLH) at a Canadian tertiary care hospital between May and October 2019. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded procedural timing, distractions, delays, threats, and technical and non-technical scores. Results Mean total case time was 172 (SD ± 16) minutes and mean procedure time was 117 (SD ± 17) minutes). Correlations between total case time and team non-technical scores and procedure time and team non-technical scores were positive and moderate in strength. Medians of 83 door openings (interquartile range [IQR] 76-104), 173 distractions (IQR 19-190) and 3 threats (IQR 2-5) were identified per case. Conclusions The ORBB allowed us to identify variations in total case times and procedural times for elective TLH. There were frequent intra-operative distractions as well as latent threats noted and there was a moderately positive correlation between case times and procedure times and team non-technical skills.

As evidence and experience in minimally invasive techniques develop, minimally invasive gastrectomy appears to be an attractive option for appropriately selected cases. This chapter will discuss appropriate patient selection and learning curve of the procedure, the technique of laparoscopic gastrectomy with D2 lymphadenectomy, and considerations for postoperative management.

Study Objective Operating room delays can result from a chain of intra-operative events including technical factors, equipment failures or unavailability, and non-technical human factors. Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes of inefficiencies. Our objective was to measure and characterize procedural steps, intra-operative distractions and delays during a common minimally invasive gynecologic procedure and identify if these delays correlated with team technical and non-technical scores. Design Cross-sectional study. Setting Canadian tertiary care academic hospital. Patients or Participants Eleven patients undergoing total laparoscopic hysterectomy (TLH) between May and October 2019. Interventions Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded procedural timing, distractions, delays, threats and team technical and non-technical scores. Measurements and Main Results Mean total case time was 172 minutes (SD +/- 16 minutes) and mean procedure time was 117 minutes (SD +/- 17 minutes). Mean surgical times for the pre-operative, intra-operative and post-operative phases were 85 mins (SD ± 40 mins), 116 mins (SD ± 17 mins) and 28 mins (SD ± 16 mins) respectively. Correlations between total case time and team non-technical scores and procedure time and team non-technical scores were positive and moderate in strength. Medians of 83 door openings [interquartile range (IQR) 76-104], 173 distractions (IQR 19-190) and 3 threats (IQR 2-5) were identified per case. Conclusion The ORBB allowed us to identify variations in procedural case times for elective TLH. There were frequent intraoperative distractions as well as latent threats noted and there was a moderately positive correlation between case times and team non-technical skills.

Study Objective Operating room (OR) delays due to inefficiency can result from a chain of intraoperative events including technical factors, equipment failures or unavailability, and non-technical human factors. The newly developed Operating Room Black Box (ORBB) technology can be used to capture information during surgery which can be analyzed to potentially identify the root causes of delays and inefficiencies. We aimed to develop a procedural framework for total laparoscopic hysterectomy (TLH) in order to accurately and consistently capture the essential time points that occur during this complex laparoscopic procedure. Design Multi-disciplinary collaborative working group. Setting Canadian tertiary care academic hospital. Patients or Participants Team consisted of gynecologic surgeons, an anesthetist, an OR nurse and systems analysts. Interventions Multi-disciplinary working group collaborated to develop a procedural framework encompassing the critical steps and check points occurring during the course of a TLH. All phases of the operation were considered including pre-operative, intra-operative, and post-operative steps. Measurements and Main Results The completed framework consists of a series of procedural steps divided into three time phases: pre-operative, intraoperative and post-operative. Consensus from the group led to the identification of 7 discrete steps during the pre-operative phase, 11 intra-operative steps and 6 post-operative steps. Conclusion The development of a standardized procedural framework for TLH is the first step towards capturing data with the ORBB technology. The analysis of the captured data will allow us to analyze the non-technical skills and team performance in the OR, and ultimately develop a multi-disciplinary operating room “playbook” that can be utilized to minimize time delays and maximize OR utilization.

To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure.: Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated.: This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills.: Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027).: Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).

Tumours of the adrenal gland are very common. They can be functional or non-functional, benign or malignant or arise in the adrenal cortex or medulla. The majority of adrenal tumours are benign non-functioning adenomas that are found incidentally on abdominal imaging for another cause (adrenal incidentaloma). Due to the risk of malignancy, incidentalomas over 6 cm should be removed while those under 4 cm may be followed with serial imaging. Benign functioning adrenal adenomas can secrete aldosterone, cortisol or androgens. After appropriate work-up, all functioning adrenal lesions should be surgically removed. 60 % of cases of adrenocortical carcinoma present with symptoms of hormone excess. After work-up, localized disease is treated with surgical resection and consideration of adjuvant mitotane. Pheochromocytomas may be benign or malignant. Essential components of perioperative management include alpha blockage followed by beta blockade.

Objective:To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery.Background:Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curric

To compare the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing.Although simulators have been developed to teach laparoscopic suturing, a barrier to their wide implementation in training programs is a lack of knowledge regarding their relative training benefit and their associated cost.This prospective single-blinded randomized trial allocated 24 surgical residents to train to proficiency using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches during a Nissen fundoplication on a patient. The operating room (OR) cases were video-recorded and technical proficiency was assessed using 2 validated tools. OR performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. A cost analysis of box training, VR training, and conventional residency training across Canadian surgical programs was performed.After ex vivo training, no significant differences in laparoscopic suturing in the OR were found between the 2 groups with respect to time (P = 0.74)-global rating score (P = 0.65) or checklist score (P = 0.97). It took conventionally trained residents 6 practice attempts in the OR to achieve the technical proficiency of the ex vivo trained groups (P = 0.83). VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the FLS trainer box was $11,975.00, on the VR simulator was $77,500.00, and conventional residency training was $17,380.00. Over 5 years, box training was the most cost-effective option for all programs, and VR training was more cost-effective for programs with more 10 residents.Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training the more cost-effective option.

BackgroundThe unique skill set required for minimally invasive surgery has in part contributed to a certain portion of surgical residency training transitioning from the operating room to the surgical skills laboratory. Simulation lends itself well as a method to shorten the learning curve for minimally invasive surgery by allowing trainees to practice the unique motor skills required for this type of surgery in a safe, structured environment. Although a significant amount of important work has been done to validate simulators as viable systems for teaching technical skills outside the operating room, the next step is to integrate simulation training into a comprehensive curriculum.ObjectivesThis narrative review aims to synthesize the evidence and educational theories underlining curricula development for technical skills both in a broad context and specifically as it pertains to minimally invasive surgery.FindingsThe review highlights the critical aspects of simulation training, such as the effective provision of feedback, deliberate practice, training to proficiency, the opportunity to practice at varying levels of difficulty, and the inclusion of both cognitive teaching and hands-on training. In addition, frameworks for integrating simulation training into a comprehensive curriculum are described. Finally, existing curricula on both laparoscopic box trainers and virtual reality simulators are critically evaluated.

Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated.We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script.The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03).Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.

The purpose of this study was to explore resident perceptions regarding four current models for teaching laparoscopic suturing and to assess the current quality of training in advanced minimally invasive surgical techniques at an academic teaching center.This study included 14 senior general surgery residents (PGY 3-5) participating in a workshop in advanced laparoscopy. Four training tools were used in the course curriculum: the Fundamentals of Laparoscopic Surgery (FLS) black box suturing model, a synthetic Nissen fundoplication model, a virtual reality (VR) simulator suturing task, and a porcine jejuno-jejunostomy model. After the workshop, residents were asked to complete a questionnaire relating to their experience with laparoscopic surgery, and their opinions regarding the four training models. Model rank was analyzed with one-way ANOVA, and χ(2) analysis with Fisher's exact test was used to analyze model effectiveness.The majority of residents had strong experience in basic laparoscopic cases such as cholecystectomy and appendectomy; however, few participants had experience in advanced cases. As a group, the residents ranked the porcine model first (average 1.6, median 1), followed by the synthetic Nissen model (average 2.0, median 2), the FLS model (average 2.5, median 3), and the VR trainer (average 3.2, median 4). Finally, each resident was asked to rate the four models individually with respect to their educational value. Scores were on a Likert scale from 1 to 5. Nine of 11 (81.8%) residents rated the animal model as "extremely helpful" while only 3 of 14 (21.4%) participants rated the VR model as "extremely helpful" (p = 0.048).This study demonstrates that operative experience in advanced laparoscopy for senior residents is suboptimal. Residents learning this skill in a simulated environment prefer animal or video-trainers as teaching models rather than virtual reality. This has implications when designing a curriculum for advanced endoscopy.

The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes. This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted. Seventeen cases were identified. Patient age was 61 (range 34–75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4–3.9). Post-operative length of stay was 4 (4–6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8–2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2–30). Follow-up was 9.7 months (range 20 days–23 months), during which one patient developed recurrent disease. This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

The subthalamic nucleus (STN) is an important component of the basal ganglia (BG) and plays a major role in the pathogenesis of Parkinson's disease (PD). Hyperactivity of STN as a consequence of the loss of dopaminergic inputs to the BG is believed to be a major factor in producing the motor symptoms of PD. High-frequency (HF) deep brain stimulation (DBS) of the STN has recently become an important treatment in PD patients where medications no longer provide satisfactory therapy. However, the mechanisms underlying DBS therapy are unknown, and there is seemingly conflicting data suggesting inhibition or excitation of STN neurons. This study directly examined the effects of stimulation in STN on the activity of STN neurons in PD patients during functional stereotactic mapping prior to insertion of DBS electrodes. Electrical stimulation in STN was investigated in twelve PD patients by recording the neural activity of a cell in STN with one electrode while applying current pulses through a second electrode located about 600 microm away. Stimulation at high frequencies (100-300 Hz) was found to produce inhibition following the stimulus train in 42% of the 60 cells tested. Inhibition during the train was seen in 13 of 15 neurons where it was possible to detect such activity. Furthermore, in 44% of the cases where HF stimulation produced inhibition there was an early inhibition followed by rebound excitation and a further inhibitory period, suggesting that the inhibitions observed are due to hyperpolarization. In eight of the 25 neurons inhibited by HF stimulation, the effects of single stimuli were determined and revealed that in seven of these there was an inhibitory period of 15-20 ms following each stimulus. Thus, the present findings suggest that local HF stimulation inhibits many STN neurons. However, these studies could not determine whether the stimulus also directly excited the cell and/or its axon, but other recent findings suggest that this is likely the case. Therefore, the overall effects of DBS stimulation in STN are likely to be inhibition of intrinsic and synaptically mediated activity, and its replacement by regular high-frequency firing.

Background Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator. Methods Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles. Results Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid. Conclusion Higher-quality studies are required to appraise educational value in this field.

The purpose of this study was to investigate whether individualized deliberate practice on a virtual reality (VR) simulator results in improved technical performance in the operating room.Training on VR simulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR.This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a conventional residency training group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 3 validated assessment tools. A score of less than 60% on any component of the assessment tool resulted in the trainee practicing a specific task on the VR simulator. The DP group practiced on the simulator as per their individualized schedule. Both groups then performed another laparoscopic cholecystectomy. A blinded expert assessed the OR recordings using a validated global rating scale.Although both groups had similar technical abilities preintervention [DP: median score, 13.5 (9.3-15.0); control: median score, 14.5 (9.3-17.8); P = 0.45], the DP residents had a superior technical performance postintervention [DP: median score, 17.0 (15.3-18.5); control: median score, 12.5 (7.5-14.0); P = 0.03]. Of 8 DP residents, 6 practiced 5 basic VR tasks (median 1 trial to pass), and 7 of 8 practiced 2 advanced tasks (median 4 trials to pass).A curriculum of deliberate individualized practice on a VR simulator improves technical performance in the OR. This has implications to greatly improve the feasibility of implementing simulation-based curricula in residency training programs, rather then having them being limited to research protocols.

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

Laparoscopic colorectal surgery is considered an advanced minimally invasive procedure with a long, variable learning curve. Developing an evaluation tool is essential to ensure that individuals reach a certain level of competence prior to performing this procedure independently. To achieve standardization and wide implementation, an assessment tool must be reflective of practice across many institutions. The purpose of this study is to validate two procedure-specific evaluation tools for laparoscopic colorectal surgery that were developed using innovative consensus methodology. Two procedure-specific rating scales for laparoscopic right and sigmoid colectomy were created using the Delphi method. Nine novice and nine expert laparoscopic sigmoid colectomy videos were prospectively collected, and nine novice and ten expert laparoscopic right colectomy videos were recorded. The experts rated the videos using the procedure-specific technical skills evaluation tool for either laparoscopic right colectomy or laparoscopic sigmoid colectomy. There were statistically significant differences between the expert and novice scores on the laparoscopic right colectomy evaluation tool: the median score of novices was 63.8% and the expert score was 73.1% (p = 0.02). Similarly, there was a significant difference between the median novice score on the sigmoid tool (58.6%) compared with the median expert score (70.7%) (p = 0.003). Cronbach’s alpha was 0.82 for the right colectomy evaluation tool and 0.79 for the sigmoid rating scale. The procedure-specific evaluation tools for laparoscopic right and sigmoid colectomy demonstrate strong reliability and construct validity, and have the potential to be used for technical skills assessment and feedback.

In recent years, simulation has come to the foreground as a method of teaching technical skills to surgical trainees. Rapid changes in health care systems underlie the shift to simulation-based education in many countries. Pressures include a decrease in work hours for residents, a shortening of

Background Laparoscopic colorectal surgery (LCS) is an advanced procedure for which no objective tools exist to assess technical skill. The aim of this study was to determine expert consensus regarding items required on a rating scale for LCS, using a Delphi technique. Methods Experts rated the substeps of LCS from 1 to 5. Responses were returned to the panel until consensus (Cronbach's α ≥ .80) was reached. Substeps that 80% of experts rated as ≥4 were included in the final instrument. Results Initially, α values were .81 for sigmoid colectomy, .77 for right (medial-to-lateral) colectomy, and .74 for the lateral-to-medial approach. In the second round, α values were .83 for medial-to-lateral right colectomy and .82 for lateral-to-medial colectomy. Conclusions The Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS.

The pathophysiological changes in neural activity that characterize multiple system atrophy (MSA) are largely unknown. We recorded the activity of pallidal neurons in 3 patients with clinical and radiological features of MSA who underwent unilateral microelectrode-guided pallidotomy for disabling parkinsonism. Findings in these patients were compared with 4 control patients with a clinical diagnosis of Parkinson's disease (PD). The position, firing rates, and firing patterns of single neurons in the pallidal complex were analyzed in both MSA and PD patients. The mean spontaneous firing rate of neurons in the internal segment of the globus pallidus internus (GPii) was significantly lower in MSA than in PD patients. There were no significant differences between MSA and PD patients, however, in firing rates of neurons in the external globus pallidus (GPe) or in the external segment of GPi (GPie). In addition, no significant differences in firing pattern were found between MSA and PD patients. In conclusion, this study has shown that firing rates of neurons in GPii but not in GPie and GPe are different in MSA patients compared with that in PD patients, a finding that may reflect the poor clinical results of pallidotomy reported in patients with MSA.

Introduction Training on virtual reality (VR) simulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate to the OR. Methods This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a control group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 2 validated assessment tools. A score of Results Although pre-intervention both groups had similar technical abilities (median score DP 13.5, control 14.5, p=0.45); post intervention, the DP residents had a superior technical performance (median score DP 17, control 12.5, p=0.034). 6/8 DP residents practiced 5 basic VR tasks (median 1 trial to pass), and 7/8 practiced 2 advanced tasks (median 4 trials to pass). Conclusions Deliberate individualized practice on a VR simulator improves OR performance of a basic laparoscopic procedure. Individualizing ex-vivo training schedules can potentially reduce the resources and time required to implement a VR curriculum.