Development of an objective evaluation tool to assess technical skill in laparoscopic colorectal surgery: a Delphi methodology

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.     

3D腹腔镜在右半结肠癌全结肠系膜切除术中的应用

目的探讨3D腹腔镜下全结肠系膜切除术(CME)治疗右半结肠癌的可行性及安全性。方法回顾分析2014年1月至2016年9月在我科接受3D腹腔镜全结肠系膜切除术的18例右半结肠癌患者的临床资料,选取同期接受2D腹腔镜CME术的23例患者的相关资料,比两组在手术持续时间、术中出血量、淋巴结清扫数目、术后标本质量、住院时间、费用以及术后并发症等方面的差异。结果 3D腹腔镜组手术时间217.8±35.9 min、清扫淋巴结数目25.0±4.9枚,与2D腹腔镜组223.2±40.0 min、24.0±5.7枚比较,差异无统计学意义(P0.05)。3D腹腔镜组术中出血量96.8±24.2 mL与2D腹腔镜组124.2±43.7 mL比较,差异具有统计学意义(P0.05)。手术质量分级方面,两组均无West A级病例;3D腹腔镜组West C级17例,West B级1例;2D腹腔镜组West C级14例;West B级9例,差异具有显著性(P0.05)。3D腹腔镜组首次排气时间3.4±0.7 d、平均住院时间13.5±2.3 d、平均住院费5.2±0.7万元,与2D腹腔镜组3.3±0.8 d、12.9±2.3 d、5.4±0.9万元相比,差异无统计学意义(P0.05)。3D腹腔镜组术后并发症2例,2D腹腔镜组术后并发症4例,差异无统计学意义(P0.05)。结论 3D腹腔镜下全结肠系膜切除术治疗右半结肠癌安全可行。     

Association between plane of mesocolic dissection and recurrence after complete mesocolic excision for right-sided colon cancer: a cohort study

Aim

Dissection in the mesocolic plane is considered by some medical professionals to be crucial in complete mesocolic excision. We aimed to assess whether intramesocolic plane dissection is associated with a risk of recurrence after complete mesocolic excision for right-sided colon cancer.

Method

This is a single-centre study based on prospectively registered data on patients undergoing resection for Union for International Cancer Control Stage I–III right-sided colon adenocarcinoma during the period 2010–2017. Patients were stratified in an intramesocolic plane group or a mesocolic plane group based on a prospective assessment of fresh specimens by a pathologist. Primary outcome was the 4.2 year risk of recurrence after inverse probability treatment weighting and competing risk analyses.

Results

Of 383 patients, 4 (1%) were excluded as the specimen was assessed as muscularis propria plane, 347 (91.6%) specimens were deemed as mesocolic and 32 (8.4%) as intramesocolic. The 4.2 year cumulative incidence of recurrence after inverse probability treatment weighting was 9.1% (95% CI 6.0%–12.1%) in the mesocolic group compared with 14.0% (3.6%–24.5%) in the intramesocolic group with an absolute risk difference in favour of mesocolic plane dissection of 4.9% (−5.7 to 15.6, p = 0.37). No difference was observed in the risk of local recurrence, death before recurrence or overall survival after 4.2 years between the two groups.

Conclusion

Mesocolic plane dissection can be achieved in more than 90% of patients. The classification seems to be a guide for good surgical practice and not to be used for research purposes.     

Complete mesocolic excision in colon cancer surgery: a comparison between open and laparoscopic approach

Background Complete mesocolic excision (CME) with central vessel ligation (CVL) as performed in Erlangen offers the best long‐term outcome for colon cancer. The aim of this study was to assess specimens after laparoscopic vs open CME‐CVL macroscopically and morphometrically in patients with left and right colon cancers. Method All specimens were freshly photographed. Precise tumour morphometry and grading of the surgical plane were performed as described by pathologists in Leeds, UK. Results Thirty‐four specimens from right‐sided cancers were divided into 18 transverse colon cancers (nine laparoscopic vs nine open) and 16 caecum–ascending colon cancers (seven laparoscopic vs nine open) and 56 specimens from left‐sided cancers (33 laparoscopic vs 23 open). There was no difference between laparoscopically and open acquired left‐ and right‐sided specimens. Specimens of transverse colon displayed differences in length of central ligation to tumour (open 11.67 cm vs laparoscopic 8.72 cm, P = 0.049), length of central ligation to bowel wall (open 9.11 cm vs laparoscopic 6.5 cm, P = 0.015) and lymph node clearance (open 46.33 vs laparoscopic 39.33, P = 0.033). Conclusion Laparoscopy seems to offer specimens of similar quality after CME‐CVL surgery for colon cancer to the open approach. Issues of completeness of excision from laparoscopy are raised for tumours located in the transverse colon.     

腹腔镜与开腹完整结肠系膜切除术的疗效对比研究

目的:探讨腹腔镜与开腹结肠癌完整结肠系膜切除术(complete mesocolic excision,CME)患者术后恢复、手术质量及中期疗效的差异。方法:收集2010年12月至2013年9月124例结肠癌CME手术患者的临床资料。其中腹腔镜组66例,开腹组58例,对比分析两组患者术后恢复、肿瘤根治性、术后感染发生率及中期复发率等指标。结果:腹腔镜组在术中出血量、术后排气时间、术后下床时间、切口感染率方面均优于开腹手术组(P<0.05),两组患者近端切缘、远端切缘长度、淋巴结清扫数量及手术时间差异均无统计学意义(P>0.05)。113例(91.1%)患者获得术后随访,中位随访时间18个月,腹腔镜组与开腹组局部复发率分别为4.55%(3/66)与5.17%(3/58),两组相比差异无统计学意义(P>0.05)。结论:腹腔镜结肠癌CME手术较开腹手术可显著缩短患者术后恢复时间,且能达到与开腹手术相同的肿瘤根治范围,具有广阔的应用前景。     

手术室专科护士胜任力模型的构建

目的构建科学、合理、适合我国国情的手术室专科护士胜任力模型,为手术室专科护士的选拔、培训、评价提供参考。方法在半结构访谈及问卷调查的基础上,初步构建手术室专科护士胜任力指标,运用德尔菲法对30名手术室相关领域专家进行函询。结果专家的积极系数、权威程度及协调程度满足德尔菲法研究标准;构建的手术室专科护士胜任力模型包含专业知识、专业能力、专业态度、个人特质4个维度,22项胜任力及行为指标,并确定各指标的权重。结论手术室专科护士胜任力模型结果可靠,可作为手术室专科护士选拔、培训、考核的参考标准。     

Bimodal assessment of laparoscopic suturing skills: Construct and concurrent validity

Background The assessment of technical skills should provide objective feedback and judge suitability of progress during training. The aim of this study was to validate two objective assessment techniques for laparoscopic suturing and demonstrate a correlation between them. Methods Six experts, seven surgeons skilled in laparoscopic suturing, and 13 with no laparoscopic suturing skills were asked to place two or three intracorporeal sutures on a synthetic suture pad. The latter group was given video-based instructions prior to the execution of the sutures. Ergonomic conditions were standardized for all subjects. The procedures were recorded on videotape and two blinded observers rated the first suture of each subject on a 29-point checklist. A motion analysis system, Imperial College Surgical Assessment Device, was used to assess psychomotor skills. Results There was a significant difference in the time taken (p=0.000) and total path length (p=0.000) per suture across the groups. There were also a significant difference in the total checklist score (p=0.000) and its individual categories. The was a strong correlation between the total path length and the total checklist score (coefficient, 0.78;p<0.001). Conclusions A combination of the motion analysis system and the checklist would make the process of formative feedback during the learning of intracorporeal suturing objective and comprehensive. Online publication: 13 October 2004     

A global assessment tool for evaluation of intraoperative laparoscopic skills

BACKGROUND: There is a pressing need for an intraoperative assessment tool that meets high standards of reliability and validity to use as an outcome measure for different training strategies. The aim of this study was to develop a tool specific for laparoscopic skills and to evaluate its reliability and validity. METHODS: The Global Operative Assessment of Laparoscopic Skills (GOALS) consists of a 5-item global rating scale. A 10-item checklist and 2 visual analogue scales (VAS) for competence and case difficulty were also used. During laparoscopic cholecystectomy, 21 participants were evaluated by the attending surgeon, by 2 trained observers and by self-assessment while dissecting the gallbladder from the liver bed. RESULTS: The intraclass correlation coefficient (ICC) for the total GOALS score was .89 (95% confidence interval [CI] .74 to .95) between observers, .82 (95% CI .67 to .92) between observers and attending surgeons, and .70 (95% CI .37 to .87) between participants and attending surgeons. The ICCs (observers) for the VAS (competence) and the checklist were .69 and .70, respectively. The mean total GOALS score (observers) for novices (postgraduate years [PGYs] 1 through 3) was 13 (95% CI 10.3 to 15.7) compared with 19.4 (95% CI 17.2 to 21.5) for experienced (PGY 4 through attending surgeons, P = .0006). The VAS demonstrated a difference in scores between novice and experienced participants (P = .001); however, the task checklist did not (P = .09). CONCLUSIONS: These data indicate that GOALS is feasible, reliable, and valid. They also suggest that it is superior to the task checklist and VAS for evaluation of technical skill by experienced raters. The findings support the use of GOALS in the training and evaluation of laparoscopic skills.     

The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI

Objective  The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland.
Method  A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide .
Results  Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48–60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding.
Conclusion  Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.     

基于零缺陷管理理论构建肝胆外科加速康复评价指标体系

目的构建适用于肝胆外科的加速康复评价指标体系,为加速康复外科实施效果提供评价工具。方法在零缺陷管理理论基础上,通过文献查阅、德尔菲专家咨询法构建肝胆外科加速康复评价指标体系。结果 2轮问卷回收率均为100%,专家权威系数分别为0.920、0.919。经过2轮专家咨询,最终构建的肝胆外科加速康复评价指标体系包括3个一级指标,8个二级指标,39个三级指标;指标重要性评分均4分,变异系数0～0.166;并确定各级指标权重。结论肝胆外科加速康复评价指标体系构建合理,有较好的可信度,经验证后可作为肝胆外科加速康复质量评价工具。     

机器人与腹腔镜辅助右半结肠全系膜切除术治疗右半结肠癌短中期疗效单中心、单外科医生经验

背景与目的：在过去的10年里,结肠全系膜切除术（CME）的理念得到了进一步的发展,以期望尽量减少右半结肠癌的复发,机器人技术能够克服腹腔镜手术的局限性,但其是否有明确的优势仍存在争议。因此,本研究进一步比较机器人和腹腔镜右半结肠切除术联合CME治疗右半结肠癌的疗效。方法：回顾性分析2016年7月—2021年12月中国人民解放军陆军特色医学中心收治的169例行右半结肠CME治疗的右半结肠癌患者临床资料。手术均由一名外科医生完成,其中,61例行达芬奇机器人辅助右半结肠CME （机器人组）;108例行腹腔镜辅助右半结肠CME （腹腔镜组）。比较两组患者相关临床指标。结果：两组术前一般资料差异均无统计学意义（均P>0.05）。两组患者均无围手术期死亡病例。机器人组的手术中转开腹率明显低于腹腔镜组（0 vs. 6.5%,P=0.042）,腹腔镜中转的主要原因为严重的腹腔粘连（4例）与肿瘤巨大影响手术视野及操作（3例）。机器人组总手术时间明显长于腹腔镜组（221.1minvs.186.0min, P<0.001）、总住院费用明显高于腹腔镜组（90371.5元vs.65136.3元,P&...     

Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis

Aim The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow. Method A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work‐up, operative surgery and anaesthesia were identical between groups. Results No significant difference was demonstrated in age, mean 67 (26–91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn’s disease (C) 8, (F) 7. Fellow’s mean operative time was significantly longer at 123 min (95%CI 117–134) compared to the consultant trainer −105 min. (95%CI 98–111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30‐day readmission rates were similar. Conclusion In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.     

居家养老环境风险评估体系的构建

目的 构建居家养老环境风险评估指标体系,为开展老年人居家环境风险评估提供测评工具.方法 采用文献研究法、焦点小组讨论法、德尔菲专家咨询法筛选评估指标,运用层次分析法确定指标权重,建立老年人居家养老环境风险评估体系.结果 2轮专家咨询问卷有效回收率分别为92.31％、86.11％,权威系数分别为0.878、0.892;Ⅰ级指标协调系数分别为0.276、0.291;最终构建的居家养老环境风险评估指标体系包括Ⅰ级指标9个和Ⅱ级指标43个,并确定各级指标权重.结论 居家养老环境风险评估体系被专家认可,评估指标体系的内容全面、权重合理,但需进一步在社区开展实证研究.     

结肠癌完整结肠系膜切除术的可行性与安全性的Meta分析

目的评价结肠癌完整结肠系膜切除术（CME）的可行性与安全性。方法计算机检索万方、CNKI、CBM、维普、PubMed、Medline、OVID、Elsevier、IsIWebofKnowledge平台（SCI、ISIP、CCR、IC）和Cochrane等近5年来公开发表的有关CME与传统结肠癌手术的随机对照试验（RCT）或非随机对照试验（RNT）文献,严格按标准筛选后,评估文献质量并提取数据资料,最后用ReviewManager5．1软件进行系统评价。结果共纳入8篇非随机对照试验文献。计有病例1209例,其中CME组615例,对照组594例。Meta分析结果显示：（1）CME在术中出血量少于传统手术（WMD=-13．05,95％CI：-25．03—1．07,P=0．03）,在手术时间上两组差异无统计学意义（WMD=O．46,95％CI：-26．50～27．41,P=0．97）;（2）CME在术后病理标本淋巴结检出数、平均切除结肠长度和系膜面积以及营养血管长度等方面均优于传统结肠癌手术（分别为P〈0．01、P〈0．01、P〈0．01和P〈0．05）;（3）两组术后首次排气时间和住院时间差异无统计学意义（P=0．87,P=0．05）;（4）CME并没有增加手术并发症发生率（P=0．74）。结论CME符合胚胎解剖学、肿瘤外科学和精细外科学理念,安全、可行．有望成为结肠痛规范化的手术方式．     

A tool‐kit for the quantitative assessment of proficiency in laparoscopic colorectal surgery

Aim Laparoscopic colorectal surgery includes operative procedures of varying complexity, and traditional assessment tools may not be enough to assess competence. This study defines quantitative tools for assessing proficiency in laparoscopic colorectal surgery. Method A single surgeon’s 11‐year experience was subdivided into five phases with equal numbers of patients. A tool‐kit, with specific tools defined as the complexity score, the conversion score, the technical score, the training score and the proficiency score, has been developed and used to evaluate each phase of the experience. Results There were 400 patients, with 80 in each of the five phases. The complexity score increased from 23.75 to 63.75 over the five phases. Similar increases were also demonstrable in the conversion score (from 0.45 to 15.45), the technical score (from 30 to 96.5), the training score (from 5.8 to 34.8) and the overall proficiency score (from 15 to 52.63). Conclusion The results show that it is possible to quantify the workload in laparoscopic colorectal surgery and to assess increasing proficiency using a simple, reproducible and reliable tool‐kit.     

老年群体心理健康危机评价指标的构建

目的构建合理适用的老年群体心理健康危机评价指标,为针对性干预提供有效测评工具。方法采用文献查阅、大样本调查、专家咨询法确立评价指标,应用层次分析法确定各评价指标权重。结果构建成包含5个一级指标、23个二级指标的评价指标;专家的积极度分别94.4%、100%,熟悉度均分4.7,评价指标的CR=0.037。结论本评价指标内容、结构及权重合理,可初步用于老年群体的心理健康状况测评。