Clinical and educational proficiency gain of supervised laparoscopic colorectal surgical trainees

Background

The self-taught learning curve in laparoscopic colorectal surgery (LCS) is between 100 and 150 cases. Supervised training has been shown to shorten the proficiency gain curve of senior specialist surgeons. Little is known about the learning curve of LCS trainees undergoing mentored training. The aim of this study was to analyze the proficiency gain curve and clinical outcomes of English surgical trainees during laparoscopic colorectal surgery fellowships.

Methods

In 2010 the educational, Web-based platform from the National Training Program in Laparoscopic Colorectal Surgery in England was newly available to surgical trainees undertaking a laparoscopic colorectal fellowship. These fellows were asked to submit clinical outcomes, including patient demographics and case specifications. In addition, self-perceived performance was evaluated using a validated task-specific self-assessment form [global assessment scale (GAS) range 1–6]. Proficiency gain curves and learning rates were evaluated using risk-adjusted (RA) cumulative sum (CUSUM) curves.

Results

Of 654 cases 608 were included for analysis. The clinical outcomes included 9.2 % conversions, 16.9 % complications, 4 % reoperations, 2.6 % readmissions and a 0.8 % in-hospital mortality rate. RA CUSUM curves for complications and reoperation do not show a learning effect. However, the RA CUSUM curve for conversion has an inflection point at 24 cases. The GAS CUSUM curves for ‘setup’ and ‘exposure’ have inflection points at case 15 and case 29 respectively. The curves for ‘mobilization of colon,’ ‘vascular pedicle’ and ‘anastomosis’ plateau towards the end of the training period. ‘Flexure’ and ‘mesorectum’ do not of reach a plateau by case 40.

Conclusions

Supervised fellowships provide training in LCS without compromising patient safety. Forty cases are required for the fellows to feel confident to perform the majority of tasks except dissection of the mesorectum and flexure, which will require further training.     

Initial Experience of Robotic Gastrectomy and Comparison with Open and Laparoscopic Gastrectomy for Gastric Cancer

Background

Robotic gastrectomy has become more popular in the treatment of gastric cancer, especially in Asian countries. Until now, few studies have compared robotic surgery with open or laparoscopic surgery for gastric cancer patients.

Methods

Data were prospectively collected between January 2006 and February 2012. A total of 689 patients underwent curative resection of adenocarcinoma of the stomach. Patients were separated into three groups according to the different surgical approaches used (586 open, 64 laparoscopic, and 39 robotic). The clinicopathological characteristics and surgical outcomes of the three groups were compared.

Results

The open group was associated with a larger tumor size, more D2 dissection, more advanced tumor stage, and more blood loss than the groups treated with laparoscopic and robotic methods. Robotic gastrectomy was associated with female predominance, less blood loss, shorter hospital stay, and longer operative time than open and laparoscopic gastrectomy. The retrieved lymph node numbers were similar between the open and robotic groups. Postoperative morbidity rates were similar among the three groups. In terms of the learning curve of robotic gastrectomy, operative time and docking time were significantly reduced in the recent robotic group (n?=?14) compared to the initial robotic group (n?=?25).

Conclusion

Robotic gastrectomy could achieve extended lymph node dissection similar to open surgery. Our results showed a significant learning curve effect in the initial 25 cases of the robotic group.     

How To Reduce the Laparoscopic Colorectal Learning Curve

Background:

The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.

Methodology:

From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.

Results:

Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70.

Conclusions:

The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12.

What is new in this paper?

The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.     

Robotic Splenectomy: What is the Real Benefit?

Background

The laparoscopic approach to a difficult splenectomy requires a longer total operative time and is frequently associated with an increased risk of bleeding and a high conversion rate.

Methods

A total of 418 elective splenectomies were registered in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between January 1995 and June 2012, of which 299 splenectomies (212 laparoscopic and 77 robotic) were performed by a single surgical team and retrospectively documented. The effect of the learning curve and the relative complexity of each type of procedure were analyzed using the Minimally Invasive Splenectomy Score, which further allowed categorizing the splenectomies as simple or difficult. Statistical analyses using the CUSUM algorithm of the intra- and postoperative parameters of the laparoscopic and robotic approaches, for both the simple and the difficult splenectomies, were performed.

Results

The results of the statistical analyses clearly indicated that there was a learning curve effect for laparoscopic splenectomy but not for robotic splenectomy. When compared with the laparoscopic approach in difficult splenectomies, the robotic approach had a shorter total operative time (84.13 vs. 97.2 min), less blood loss (30.88 vs. 156.9 ml), and decreased risk of hemorrhagic complications during surgery.

Conclusions

Laparoscopic splenectomy remains the approach of choice for simple splenectomies in the surgical treatment for common indications. The robotic system is particularly beneficial in difficult splenectomies (i.e., partial splenectomy, splenectomy in liver cirrhosis, splenic tumors, or malignant hemopathies).     

Identifying Specific Surgical Tools and Methods for Laparoscopic Colorectal Operations in Obese Patients

Objective

Laparoscopic operations for obese patients remain challenging due to technical difficulties at operation as well as higher comorbidities and high risk of postoperative complications. The aim of this study is to identify specific surgical tools and methods for laparoscopic colorectal operations for obese patients, applying knowledge of previous literature as well as our expertise in both laparoscopic and bariatric operations.

Conclusions

Current knowledge of bariatric surgery is invaluable in establishing a ??customized?? approach for laparoscopic colorectal operations in obese patients. The instruments routinely used during surgery on patients with normal body mass index (BMI) should often be modified and substituted according to the patient??s BMI. We believe such an approach will prove beneficial to surgeons performing laparoscopic operations on obese patients.     

Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3-phase learning process comparison

Background

Robotic surgery has advantages to perform rectal cancer by its ergonomic designs and advanced technologies. However, it was uncertain whether these core robotic technologies could shorten the learning curve. The aim of this study is to investigate the learning curve of robotic rectal cancer surgery and to compare the learning curve phases with respect to perioperative clinicopathologic outcomes.

Methods

From April 2006 to August 2011, a total of 130 consecutive patients who were diagnosed with rectal cancer underwent a robotic low anterior resection (LAR) using the hybrid technique by a single surgeon at Severance Hospital. The moving average method and the cumulative sum (CUSUM) were used to analyze the learning curve. The risk-adjusted CUSUM (RA-CUSUM) analysis was used to evaluate the points, which showed completion of surgical procedures in terms of R1 resection, conversion, postoperative complications, harvested lymph nodes less than 12, and local recurrence. Perioperative clinical outcomes and pathologic results were compared among the learning curve phases.

Results

According to the CUSUM, the learning curve was divided into three phases: phase 1 [the initial learning period (1st–44th case), n = 44], phase 2 [the competent period (45th–78th case), n = 34], and phase 3 [the challenging period (79th–130th case), n = 52]. RA-CUSUM showed the minimum value at the 75th case, which suggested technical competence to satisfy feasible perioperative outcomes. The total operation time tended to decrease after phase 1 and so did the surgeon console time and docking time. Postoperative complications and pathologic outcomes were not significantly different among the learning phases.

Conclusions

The learning curve of robotic LAR consisted of three phases. The primary technical competence was achieved at phase 1 of the 44th case according to the CUSUM. The technical completion to assure feasible perioperative outcomes was achieved at phase 2 at the 75th case by the RA-CUSUM method.     

Proficiency training on a virtual reality robotic surgical skills curriculum

Introduction

The clinical application of robotic surgery is increasing. The skills necessary to perform robotic surgery are unique from those required in open and laparoscopic surgery. A validated laparoscopic surgical skills curriculum (Fundamentals of Laparoscopic Surgery or FLS?) has transformed the way surgeons acquire laparoscopic skills. There is a need for a similar skills training and assessment tool for robotic surgery. Our research group previously developed and validated a robotic training curriculum in a virtual reality (VR) simulator. We hypothesized that novice robotic surgeons could achieve proficiency levels defined by more experienced robotic surgeons on the VR robotic curriculum, and that this would result in improved performance on the actual daVinci Surgical System?.

Methods

25 medical students with no prior robotic surgery experience were recruited. Prior to VR training, subjects performed 2 FLS tasks 3 times each (Peg Transfer, Intracorporeal Knot Tying) using the daVinci Surgical System? docked to a video trainer box. Task performance for the FLS tasks was scored objectively. Subjects then practiced on the VR simulator (daVinci Skills Simulator) until proficiency levels on all 5 tasks were achieved before completing a post-training assessment of the 2 FLS tasks on the daVinci Surgical System? in the video trainer box.

Results

All subjects to complete the study (1 dropped out) reached proficiency levels on all VR tasks in an average of 71 (± 21.7) attempts, accumulating 164.3 (± 55.7) minutes of console training time. There was a significant improvement in performance on the robotic FLS tasks following completion of the VR training curriculum.

Conclusions

Novice robotic surgeons are able to attain proficiency levels on a VR simulator. This leads to improved performance in the daVinci surgical platform on simulated tasks. Training to proficiency on a VR robotic surgery simulator is an efficient and viable method for acquiring robotic surgical skills.     

Laparoscopic appendectomy by residents: evaluating outcomes and learning curve

Background

Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome.

Methods

All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics, clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups.

Results

Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged.

Conclusion

Operative duration and complications can be reduced with increasing experience of a resident.     

Robotic single-site hysterectomy: feasibility, learning curve and surgical outcome

Background

The field of laparoscopy has undergone several changes to improve the morbidity and cosmesis of laparoscopic surgery. The robotic single-site surgery is the inevitable hybridization of robotic technology with laparoendoscopic single-site surgery.

Methods

Perioperative information of 12 robotic single-site hysterectomies (R-SSH) were collected to evaluate the surgical feasibility and the possible influence of the body mass index (BMI) and the uterine weight on operative times.

Results

The mean operative time was 85 ± 33 min (range, 355 to 149 min), the mean docking time was 9 ± 3 min, and the mean console time was 76 ± 33 min. The mean blood loss was 80 ± 18 mL, and the median weight of resected uteri was 220 ± 45 g. No serious postoperative complications occurred. The CUSUM learning curve was observed to consist of two different phases: phase 1 (the initial 6 cases) and phase 2 (the last 6 cases) with significant reduction in operative and console time observed between the two phases. For BMI, no correlation was found with operative times, console times, and docking times, and no correlation was found between uterine weight and operative time.

Conclusions

This series, identifying two different phases of the learning curve and suggesting that the initial learning phase for the procedure can be achieved after six cases, confirms the feasibility and safety of a robotic approach for single-site hysterectomy. However, the limits of this study mainly rely on the limited casuistic and short follow-up, although the preliminary results appear promising. Larger series and prospective studies comparing R-SSH hysterectomy with standard robotic multiport hysterectomy are necessary to define properly the role of this innovative surgical technique.     

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis

Background

Laparoscopic pancreaticoduodenectomy (LPD), an advanced minimally invasive technique, has demonstrated advantages to open pancreaticoduodenectomy (OPD). However, this complex procedure requires a relatively long training period to ensure technical proficiency. This study was therefore designed to analyze the learning curve for LPD.

Methods

From October 2010 to September 2015, 63 standard pancreaticoduodenectomy procedures were to be performed laparoscopically by a single surgeon at the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 57 patients were included in the study. Data for all the patients, including preoperative, intraoperative, and postoperative variables, were prospectively collected and analyzed. The learning curve for LPD was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All of the variables among the learning curve phases were compared.

Results

Based on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–11), phase II represented the technical competence period (cases 12–38), and phase III was regarded as the challenging period (cases 39–57). The operative time, intraoperative blood loss, and postoperative ICU demand significantly decreased with the learning curve. More lymph nodes were collected after the initial learning period. There were no significant differences in terms of postoperative complications or the 30-day mortality among the three phases. More challenging cases were encountered in phase III.

Conclusions

According to this study, the learning curve for LPD consisted of three phases. Conservatively, to attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience.

     

Robot-assisted anterior lumbar interbody fusion (ALIF) using retroperitoneal approach

Background

Over the past few years, robot-assisted surgery has become increasingly popular, affecting virtually all surgical fields. It has been proven to overcome pitfalls of laparoscopic procedures, such as high complication rates and steep learning curve. We have, therefore, performed experimental anterior lumbar interbody fusion (ALIF) using retroperitoneal approach in swine model to test the feasibility of robot-assisted surgery in spinal surgery.

Method

In this report, we describe the setup with the da Vinci® surgical system, operative method, result and discuss technical aspects and the future of robot-assisted ALIF.

Findings

Experimental retroperitoneal dissection using robotic surgical system was successfully performed with great visual cue, minimal retraction and minimal bleeding.

Conclusion

Although retroperitoneal approach for spinal fusion has never been attempted with robotic surgical system, we could demonstrate the possibility with swine model. Further studies and development of appropriate instruments will bring minimally invasive spine surgery to a new era.     

Outcomes of Robotic-Assisted Colorectal Surgery Compared with Laparoscopic and Open Surgery: a Systematic Review

Background

Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.

Methods

Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms “robot,” “robotic,” “colon,” “rectum,” “colorectal,” and “colectomy.” Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.

Results

Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.

Conclusion

Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of robotic surgery.

     

A Randomised Comparative Study Evaluating Learning Curves of Novices in a Basic Single-Incision Laparoscopic Surgery Task

Objective

There is currently no objective quantification of the temporal changes in performance associated with a novice surgeon learning single-incision laparoscopic surgery (SILS) operative tasks. Analysing learning curves allows us to objectively quantify performance. The aim was to evaluate if the rate of learning and ultimate proficiency level reached in SILS when using straight or articulating instruments is different to conventional laparoscopy and if training in laparoscopy influences learning or proficiency for SILS.

Design and Setting

Thirty-six surgically naive medical students were randomised to complete the validated peg transfer task over 50 repetitions using a conventional laparoscopic set-up, SILS set-up with straight instruments or articulated instruments or SILS set-up after having reached proficiency using a conventional laparoscopy.

Results

There was a significant increased overall proficiency between the group trained in conventional laparoscopy and all other groups (p?<?0.01), with no difference between the other groups. There was no difference in the rate of learning between the groups. There was no difference in the ultimate proficiency level (p?=?0.671) or rate of learning (p?=?0.63) when using straight or articulating instruments. There was no difference in ultimate proficiency level (p?=?0.59) or learning rate (p?=?0.219) seen in the SILS group that had prior training on the task with a conventional laparoscopic set-up.

Conclusions

The results of this study indicate that the proficiency reached using a conventional laparoscopic set-up cannot be matched using a SILS configuration for the novice surgeon and that the choice of straight or articulated instruments as well as previous laparoscopic training does not confer an advantage in this basic task.     

Robot-assisted Gastrectomy for Gastric Cancer: Current Status and Technical Considerations

Background

Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature.

Methods

We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

Results

In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer.

Conclusions

While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.     

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision

Background

Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program.

Methods

A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously.

Results

Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery.

Conclusions

Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.     

Validation of a virtual reality-based robotic surgical skills curriculum

Background

The clinical application of robotic-assisted surgery (RAS) is rapidly increasing. The da Vinci Surgical System? is currently the only commercially available RAS system. The skills necessary to perform robotic surgery are unique from those required for open and laparoscopic surgery. A validated laparoscopic surgical skills curriculum (fundamentals of laparoscopic surgery or FLS?) has transformed the way surgeons acquire laparoscopic skills. There is a need for a similar skills training and assessment tool specific for robotic surgery. Based on previously published data and expert opinion, we developed a robotic skills curriculum. We sought to evaluate this curriculum for evidence of construct validity (ability to discriminate between users of different skill levels).

Methods

Four experienced surgeons (>20 RAS) and 20 novice surgeons (first-year medical students with no surgical or RAS experience) were evaluated. The curriculum comprised five tasks utilizing the da Vinci? Skills Simulator (Pick and Place, Camera Targeting 2, Peg Board 2, Matchboard 2, and Suture Sponge 3). After an orientation to the robot and a period of acclimation in the simulator, all subjects completed three consecutive repetitions of each task. Computer-derived performance metrics included time, economy of motion, master work space, instrument collisions, excessive force, distance of instruments out of view, drops, missed targets, and overall scores (a composite of all metrics).

Results

Experienced surgeons significantly outperformed novice surgeons in most metrics. Statistically significant differences were detected for each task in regards to mean overall scores and mean time (seconds) to completion.

Conclusions

The curriculum we propose is a valid method of assessing and distinguishing robotic surgical skill levels on the da Vinci Si? Surgical System. Further study is needed to establish proficiency levels and to demonstrate that training on the simulator with the proposed curriculum leads to improved robotic surgical performance in the operating room.     

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

Purpose

The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time.

Methods

From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years.

Results

Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p?=?0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p?=?0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p?=?0.04). Wound or abdominal infection (4.7 vs. 2.3%, p?=?0.01) and respiratory complications (7.4 vs. 4.7%, p?=?0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402).

Conclusion

Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

     

Diffusion of robotics into clinical practice in the United States: process, patient safety, learning curves, and the public health

Background

Robotic technology disseminated into urological practice without robust comparative effectiveness data.

Objective

To review the diffusion of robotic surgery into urological practice

Methods

We performed a comprehensive literature review focusing on diffusion patterns, patient safety, learning curves, and comparative costs for robotic radical prostatectomy, partial nephrectomy, and radical cystectomy

Results

Robotic urologic surgery diffused in patterns typical of novel technology spreading among practicing surgeons. Robust evidence-based data comparing outcomes of robotic to open surgery were sparse. Although initial Level 3 evidence for robotic prostatectomy observed complication outcomes similar to open prostatectomy, subsequent population-based Level 2 evidence noted an increased prevalence of adverse patient safety events and genitourinary complications among robotic patients during the early years of diffusion. Level 2 evidence indicated comparable to improved patient safety outcomes for robotic compared to open partial nephrectomy and cystectomy. Learning curve recommendations for robotic urologic surgery have drawn exclusively on Level 4 evidence and subjective, non-validated metrics. The minimum number of cases required to achieve competency for robotic prostatectomy has increased to unrealistically high levels. Most comparative cost-analyses have demonstrated that robotic surgery is significantly more expensive than open or laparoscopic surgery.

Conclusions

Evidence-based data are limited but suggest an increased prevalence of adverse patient safety events for robotic prostatectomy early in the national diffusion period. Learning curves for robotic urologic surgery are subjective and based on non-validated metrics. The urological community should develop rigorous, evidence-based processes by which future technological innovations may diffuse in an organized and safe manner.     

Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. Potential advantages and limits of an expensive approach

Background

This study was designed to compare the laparoscopic subtotal splenectomy with the robotic approach in patients with hereditary spherocytosis.

Methods

Thirty-two consecutive subtotal splenectomies by minimal approach in patients with hereditary spherocytosis were analyzed (10 robotic vs. 22 laparoscopic subtotal splenectomies).

Results

A significant difference was found for the robotic approach regarding blood loss, vascular dissection duration, and splenic remnant size. Follow-up for 4–103?months was available.

Conclusions

Subtotal splenectomy seems to be a suitable candidate for robotic surgery, requiring a delicate dissection of the splenic vessels and a correct intraoperative evaluation of the splenic remnant. Robotic subtotal splenectomy is comparable to laparoscopy in terms of hospital stay and complication. The main benefits are lower blood loss rate, vascular dissection time, and a better evaluation of the splenic remnant volume.     

Resident Training in Laparoscopic Colorectal Surgery: Role of the Porcine Model

Background

Laparoscopic colorectal surgery (LCRS) is an effective option for the treatment of various colorectal conditions. However, its implementation in surgical practice is still limited, and there are no clear guidelines for residency training requirements or evaluation of the level of expertise. The aim of this study was to assess the level of practical expertise of senior residents regarding LCRS in an animal porcine model.

Methods

At the Department of Biosciences of Rome, Tecnopolo of Castel Romano, 50 senior residents underwent training sessions on a porcine model under the direction of attending laparoscopic surgeons. A total of 20 residents underwent box trainer preparation before starting the surgical procedure on the animal model; and a group of 6 repeated the course 3?months after the first session.

Results

Overall, 90?% of the residents needed help during the surgical procedures, and only 9 residents (18?%) showed a high level of confidence when performing the surgery. Video-trainer preparation helped residents increase their laparoscopic ability (p?=?0.04). Residents who attended two training courses showed significant improvement regarding the duration of the procedures, rate of complications, and the need of a tutor.

Conclusions

The study demonstrated that the experience of senior surgical residents in regard to performing LCRS is less than ideal. A national training program should carefully consider the present quality of training in Italy and attempt to develop and integrate alternative methods for teaching laparoscopic surgery, perhaps by having an animal model laboratory.