Video-based tools for surgical quality assessment of technical skills in laparoscopic procedures: a systematic review

Comparative study of the learning curves for percutaneous endoscopic interlaminar lumbar discectomy and unilateral biportal endoscopy techniques

BACKGROUND

Minimally invasive spinal surgery techniques, such as Percutaneous Endoscopic Interlaminar Lumbar Discectomy (PEID) and Unilateral Biportal Endoscopy (UBE), have been developed to reduce surgical morbidity and enhance patient recovery. Although both techniques demonstrate promising clinical outcomes, the learning curves required for surgeons to achieve proficiency with these methods remain unclear.

OBJECTIVE

To compare the learning curves of PEID and UBE in the treatment of lumbar disc herniation.

METHODS

We conducted a retrospective analysis of 173 patients who underwent either PEID (n = 94) or UBE (n = 79), performed by two independent surgeons between January 2020 and January 2022. Eligible patients were aged 18-75 years, diagnosed with lumbar disc herniation, and had no previous spinal surgeries at the affected level. Metrics analyzed included operative time, intraoperative blood loss, postoperative recovery, complication rates, and clinical outcomes, assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores.

RESULTS

The PEID group demonstrated significantly shorter operative times (99.96 ± 34.74 min vs. 116.52 ± 47.20 min, P < 0.05) and less blood loss (20.85 ± 11.06 ml vs. 80.19 ± 22.81 ml, P < 0.01) compared to the UBE group. Both techniques showed significant improvements in VAS and ODI scores postoperatively, with no significant differences between the groups at any follow-up points. Learning curve analysis revealed that operative times for PEID stabilized at approximately 70 min after about 40 cases, while UBE stabilized at around 65 min after approximately 35 cases. Complication rates were low, and patient satisfaction was high in both groups. According to the Modified MacNab criteria, 83% of patients in the PEID group and 79.7% in the UBE group achieved excellent outcomes, while only 5.3% and 3.8% of patients experienced fair or poor outcomes in the PEID and UBE groups, respectively.

CONCLUSION

Both PEID and UBE are effective minimally invasive techniques for the treatment of lumbar disc herniation, offering comparable clinical outcomes and low complication rates. However, PEID is associated with shorter operative times and reduced intraoperative blood loss. Understanding the learning curves of these techniques is crucial for surgeons to improve proficiency and optimize patient outcomes.

Development and usability of an endoscopist report card assessing ERCP quality

BACKGROUND AND AIMS

Audit and feedback (A&F) for ERCP is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist "report cards" are one such A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability, and feasibility through usability testing.

METHODS

A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AEs). Exploratory analyses from a prospective multicenter registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semistructured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated postinterview usability instruments were administered. Feedback was incorporated to create a final report card.

RESULTS

The report card included domains of technical parameters, AE rates and prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Postinterview instruments revealed adequate appropriateness and acceptability. PREMs were believed by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation because of reliance on difficult-to-obtain granular intraprocedural data.

CONCLUSIONS

We designed and tested an ERCP report card that has the potential to be an effective A&F intervention for endoscopists in clinical practice. Although feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool.

Essential components and validation of multi-specialty robotic surgical training curricula: a systematic review

INTRODUCTION

The rapid adoption of robotic surgical systems has overtook the development of standardized training and competency assessment for surgeons, resulting in an unmet educational need in this field. This systematic review aims to identify the essential components and evaluate the validity of current robotic training curricula across all surgical specialties.

METHODS

A systematic search of MEDLINE, EMBASE, Emcare, and CINAHL databases was conducted to identify the studies reporting on multi-specialty or specialty-specific surgical robotic training curricula, between January 2000 and January 2024. We extracted the data according to Kirkpatrick's curriculum evaluation model and Messick's concept of validity. The quality of studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

From the 3687 studies retrieved, 66 articles were included. The majority of studies were single-center ( n = 52, 78.8%) and observational ( n = 58, 87.9%) in nature. The most commonly reported curriculum components include didactic teaching ( n = 48, 72.7%), dry laboratory skills ( n = 46, 69.7%), and virtual reality (VR) simulation ( n = 44, 66.7%). Curriculum assessment methods varied, including direct observation ( n = 44, 66.7%), video assessment ( n = 26, 39.4%), and self-assessment (6.1%). Objective outcome measures were used in 44 studies (66.7%). None of the studies were fully evaluated according to Kirkpatrick's model, and five studies (7.6%) were fully evaluated according to Messick's framework. The studies were generally found to have moderate methodological quality with a median MERSQI of 11.

CONCLUSIONS

Essential components in robotic training curricula identified were didactic teaching, dry laboratory skills, and VR simulation. However, variability in assessment methods used and notable gaps in curricula validation remain evident. This highlights the need for standardized evidence-based development, evaluation, and reporting of robotic curricula to ensure the effective and safe adoption of robotic surgical systems.

Methods of surgical quality assurance in cervical and endometrial cancer trials: a systematic review and meta-analysis

Surgery quality in gynecology oncology trials varies, potentially biasing results. This systematic review examines methods for assuring surgical quality in multi-center gynecologic oncology trials and the impact on patient outcomes. A systematic search (2000-2023) was conducted in Medline, Embase, and Web of Science. Multi-center randomized controlled trials reporting on surgical endometrial and cervical cancer trials and lymph node harvest, short-term mortality, or conversion rate were included. Studies were assessed using a 10-point checklist to determine surgical quality. This was used to assess the association with variation in lymph node harvest, post-operative mortality, and conversion rate. Overall, 5963 titles and abstracts were screened for their eligibility and 10 studies reporting on 22 surgical-only arms were included for further analysis. The total number of included patients was 7434 from 366 centers. Analysis showed that standardization of surgical approach (β = -6.6, 95%, p = .043), standardization of the extent of lymphadenectomy (β = -2.432, p = .004), video assessment pre-trial (β = -3.492, p = .04) and monitoring of data including clinical outcome measures (β = -4.018, p = .009) were significantly associated with reducing variation in lymph node harvest. It also showed that standardization of the extent of lymphadenectomy (β = -0.718, p < .001) and pre-trial case/procedure volume assessment (β = -0.531, p = .049) were significantly associated with reducing short-term mortality. The regression model showed standardization of the extent of lymphadenectomy (β = -3.123, p = .034) was significantly associated with reducing conversion rate. In conclusion, the heterogeneity of surgical quality measures showed that there is no clear consensus on the approach to delivering surgical quality assurance in gynecology oncology trials. The analysis in this evidence synthesis has shown a potential association between different aspects of surgical quality assurance and clinical outcomes. Further research is required to develop a framework ensuring surgical quality deliverance in gynecology oncology trials.

Artificial intelligence and the education of future surgeons

Artificial intelligence (AI) has the potential to reshape surgical education by enabling personalized feedback, advanced competency evaluations, and enhancing resident selection processes. Through AI-driven simulations and real-time feedback systems, surgical trainees can engage in adaptive learning environments that promote deliberate practice and accelerated skill acquisition. Moreover, intraoperative AI tools may soon offer decision support, guiding surgeons during complex procedures. However, integrating AI into surgical education and practice comes with significant challenges. These include the need for high-quality datasets, the transition of AI systems from simulated environments to actual surgeries, and the ethical implications of data privacy, algorithmic bias, and surgeon autonomy. Overreliance on AI could de-skill surgeons, while biased algorithms may perpetuate disparities in resident selection and performance evaluations. To address these issues, regulatory frameworks must be developed to ensure responsible AI use, focusing on transparency, validation, and augmentation rather than replacement of human expertise. Surgeons must decide where AI's use is appropriate, questioning whether capability alone justifies adoption. With careful consideration of these challenges, AI has the potential to revolutionize surgical education and foster a new generation of highly skilled and competent surgeons.

Video-based surgical quality assessment of minimally invasive right hemicolectomy by medical students after specific training

BACKGROUND

Recently, a competency assessment tool has been developed within the RIGHT project, a national quality improvement program for minimally invasive right hemicolectomy in patients with colon cancer. This study aimed to evaluate whether trained medical students can reliably evaluate minimally invasive right hemicolectomy videos using a competency assessment tool.

METHODS

Nine expert colorectal surgeons, 13 trained medical students, and 17 untrained medical students assessed the surgical quality of 6 full-length minimally invasive right hemicolectomy videos with the competency assessment tool. The expert surgeons were trained using the competency assessment tool by the RIGHT project leaders, who were also involved in the development and validation of the competency assessment tool. Training for medical students included anatomy, step-by-step procedure explanation, and competency assessment tool review with 2 supervised video assessments. The untrained students were taught only anatomy and minimally invasive right hemicolectomy steps. The intraclass correlation coefficient was calculated to determine inter-rater reliability, and analysis of variance with the Bonferroni correction for multiple testing was used to assess potential differences between the groups per video.

RESULTS

The trained students demonstrated an overall excellent inter-rater reliability (intraclass correlation coefficient score of 0.885). When their scores were combined with those of the expert surgeons, a high inter-rater reliability was also demonstrated (intraclass correlation coefficient score of 0.945). Trained students consistently aligned with surgeons' mean total scores, also accurately identifying lower quality surgeries. Untrained students assigned statistically significantly higher scores to the 3 lower quality surgeries as compared with expert surgeons and trained students.

CONCLUSION

Among trained students, excellent inter-rater reliability and concordance with expert colorectal surgeons was found. The study highlights the potential to engage trained medical students for objective minimally invasive right hemicolectomy video assessment.

Artificial Intelligence in Surgery: A Systematic Review of Use and Validation

Background: Artificial Intelligence (AI) holds promise for transforming healthcare, with AI models gaining increasing clinical use in surgery. However, new AI models are developed without established standards for their validation and use. Before AI can be widely adopted, it is crucial to ensure these models are both accurate and safe for patients. Without proper validation, there is a risk of integrating AI models into practice without sufficient evidence of their safety and accuracy, potentially leading to suboptimal patient outcomes. In this work, we review the current use and validation methods of AI models in clinical surgical settings and propose a novel classification system. Methods: A systematic review was conducted in PubMed and Cochrane using the keywords "validation", "artificial intelligence", and "surgery", following PRISMA guidelines. Results: The search yielded a total of 7627 articles, of which 102 were included for data extraction, encompassing 2,837,211 patients. A validation classification system named Surgical Validation Score (SURVAS) was developed. The primary applications of models were risk assessment and decision-making in the preoperative setting. Validation methods were ranked as high evidence in only 45% of studies, and only 14% of the studies provided publicly available datasets. Conclusions: AI has significant applications in surgery, but validation quality remains suboptimal, and public data availability is limited. Current AI applications are mainly focused on preoperative risk assessment and are suggested to improve decision-making. Classification systems such as SURVAS can help clinicians confirm the degree of validity of AI models before their application in practice.

ESGE/ESGO/SERGS consensus statement on surgical steps in minimally invasive surgery in gynecologic oncology: transperitoneal and extraperitioneal approach for paraaortic lymphadenectomy

INTRODUCTION

Assessment of retroperitoneal nodes is an important part of the surgical staging of gynecologic cancers. Although pelvic and paraaortic lymphadenectomy have been widely described by different authors, there is little consensus on the description of the different surgical steps for each procedure. An Intergroup Committee on Onco-Gyn Minimally Invasive Surgery has been established with members of the European Society for Gynecological Endoscopy (ESGE), European Society of Gynaecological Oncology (ESGO) and the Society of European Robotic Gynaecological Surgery (SERGS). The Intergroup Committee has various objectives: writing down a surgical description of the technique, which will be assessed by a group of experts following a formal consensus method and developing a specific Objective Structured Assessment of Technical Skills (OSATS) scale for each procedure.

METHODS

A hierarchical task analysis was conducted by a working group of eight experts from the three societies in order to identify the surgical steps of transperitoneal and extraperitoneal approach in paraaortic lymphadenectomy. The selection of the definitive surgical steps was confirmed by a group of 19 experts from the different societies, following a formal consensus method. Two rounds of Delphi panel rating were considered necessary for achieving an agreement. The consensus agreement identified 29 surgical steps in transperitoneal and 17 surgical steps in extraperitoneal approach to complete a paraaortic lymphadenectomy. Once the description of the procedure and the consensus were established, an Objective specific Scale for the Assessment of Technical Skills for Paraaortic lymphadenectomy (PA-OSATS) in the transperitoneal and extraperitoneal approach was developed.

RESULTS

In the first round of rating we found that 28 steps out of 29 in the transperitoneal approach and 13 out of 17 in the extraperitoneal approach did not reach a strong degree of agreement. They were reformulated based on comments made by the experts, and submitted to a second round of rating and this finally achieved an agreement.

CONCLUSION

We defined a list of surgical steps in transperitoneal and extraperitoneal approach in paraaortic lymphadenectomy and a specific PA-OSATS scale for these procedures. This tool will be useful for teaching, assessing and standardizing this surgical procedure.

Initial surgical performance in robot-assisted radical prostatectomy is associated with clinical outcomes and learning curves

BACKGROUND

The association between surgical performance ratings and clinical outcomes in robotic surgery is poorly understood. Additionally, no studies have reported on the relationship between the surgeon's initial case-skill evaluation and the learning curve in robot-assisted surgery. We evaluated whether an objective surgical technique evaluation score for initial robot-assisted radical prostatectomy (RARP) was associated with clinical outcomes and surgeons' learning curves.

METHODS

Six surgeons who were trained in and started to perform RARP at our institution were included. Anonymized, unedited videos of each surgeon's 10th RARP case were evaluated by three reviewers, using modified Objective Structured Assessment of Technical Skill (OSATS) scores. We then divided the surgeons into two groups on the basis of these OSATS scores. We retrospectively compared the clinical outcomes and learning curves of the console time of the two groups for consecutive RARPs, performed from March 2018 to July 2023.

RESULTS

We analyzed 258 RARPs (43 cases/surgeon), including 129 cases performed by high-OSATS score surgeons (18.2-19.3 points) and 129 cases performed by low-OSATS score surgeons (11.9-16.0 points). Overall, the high-OSATS score group had significantly shorter operation and console times than the low-OSATS score group did (both P < 0.01) and their patients' rate of continence recovery by 3 months post-RARP was significantly higher (P = 0.03). However, complications, blood loss, and positive margins did not differ between the groups (P = 0.08, P = 0.51, and P = 0.90, respectively). The high-OSATS score group had a significantly shorter console time than the low-OSATS score group did after the 11-20 cases.

CONCLUSIONS

The OSATS score in early RARP cases can predict subsequent surgical outcomes and surgeons' learning curves.

Objective assessment tools in laparoscopic or robotic-assisted gynecological surgery: A systematic review

INTRODUCTION

There is a growing emphasis on proficiency-based progression within surgical training. To enable this, clearly defined metrics for those newly acquired surgical skills are needed. These can be formulated in objective assessment tools. The aim of the present study was to systematically review the literature reporting on available tools for objective assessment of minimally invasive gynecological surgery (simulated) performance and evaluate their reliability and validity.

MATERIAL AND METHODS

A systematic search (1989-2022) was conducted in MEDLINE, Embase, PubMed, Web of Science in accordance with PRISMA. The trial was registered with the Prospective Register of Systematic Reviews (PROSPERO) ID: CRD42022376552. Randomized controlled trials, prospective comparative studies, prospective single-group (with pre- and post-training assessment) or consensus studies that reported on the development, validation or usage of assessment tools of surgical performance in minimally invasive gynecological surgery, were included. Three independent assessors assessed study setting and validity evidence according to a contemporary framework of validity, which was adapted from Messick's validity framework. Methodological quality of included studies was assessed using the modified medical education research study quality instrument (MERSQI) checklist. Heterogeneity in data reporting on types of tools, data collection, study design, definition of expertise (novice vs. experts) and statistical values prevented a meaningful meta-analysis.

RESULTS

A total of 19 746 titles and abstracts were screened of which 72 articles met the inclusion criteria. A total of 37 different assessment tools were identified of which 13 represented manual global assessment tools, 13 manual procedure-specific assessment tools and 11 automated performance metrices. Only two tools showed substantive evidence of validity. Reliability and validity per tool were provided. No assessment tools showed direct correlation between tool scores and patient related outcomes.

CONCLUSIONS

Existing objective assessment tools lack evidence on predicting patient outcomes and suffer from limitations in transferability outside of the research environment, particularly for automated performance metrics. Future research should prioritize filling these gaps while integrating advanced technologies like kinematic data and AI for robust, objective surgical skill assessment within gynecological advanced surgical training programs.

Effectiveness of, and Satisfaction with, a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

PURPOSE

This is the first study to assess the impact of an online microsurgical testicular sperm extraction (mTESE) masterclass. We: 1) describe the masterclass's scientific content; 2) appraise the participants' acquisition of knowledge; 3) gauge whether the extent of improvement of the participants' knowledge/skills was influenced by demographic/professional attributes; and 4) evaluate the participants' satisfaction.

MATERIALS AND METHODS

This masterclass comprised five didactic lectures followed by 4 case discussions. Online surveys assessed the above objectives using a baseline questionnaire including demographics and past mTESE experience/training, a 24-question pre- and post-quiz, and a satisfaction questionnaire.

RESULTS

Participants were between 20-70 years old, with 80.37% males, mainly from Asia, Africa, and Europe, from clinical backgrounds (69.3%), and in public practice (64.4%). Half the sample reported no past mTESE training and very low skills, ≈60% wanted considerably more training, and 50% felt that good training was not readily available. Satisfaction was 98% to >99%. Pre- and post-quiz comparisons confirmed remarkable improvements in knowledge/skills, exhibiting five striking characteristics. Improvements were a) Broad i.e., across 19 of the 24 mTESE questions; b) Deep, of magnitude, as pre-/post-quiz scores improved from mean 13.71±4.13 to 17.06±4.73; c) Highly significant, consistently with p-values <0.001; d) Inclusive i.e., all participants enhanced their mTESE knowledge/skills regardless of demographic/professional attributes; and, e) Differential, e.g., non-clinical/clinical participants improved, but the former improved relatively significantly more, those with ≤5-year experience improved significantly more than those with >5-year, those in public practice significantly more than private practice participants, and those with lower self-rating in performing mTESE significantly more than those with higher self-rating.

CONCLUSIONS

The masterclass was successful with very high satisfaction levels, and markedly improved mTESE knowledge/skills among the participants. Global Andrology Forum's model can be adopted by organizations with similar goals. Future research needs to evaluate such training to develop a practically non-existent evidence base.

Surgical quality assessment of critical view of safety in 283 laparoscopic cholecystectomy videos by surgical residents and surgeons

INTRODUCTION

Surgical quality assessment has improved the efficacy and efficiency of surgical training and has the potential to optimize the surgical learning curve. In laparoscopic cholecystectomy (LC), the critical view of safety (CVS) can be assessed with a 6-point competency assessment tool (CAT), a task commonly performed by experienced surgeons. The aim of this study is to determine the capability of surgical residents to perform this assessment.

METHODS

Both surgeons and surgical residents assessed unedited LC videos using a 6-point CVS, a CAT, using an online video assessment platform. The CAT consists of the following three criteria: 1. clearance of hepatocystic triangle, 2. cystic plate, and 3. two structures connect to the gallbladder, with a maximum of 2 points available for each criterion. A higher score indicates superior surgical performance. The intraclass correlation coefficient (ICC) was employed to assess the inter-rater reliability between surgeons and surgical residents.

RESULTS

In total, 283 LC videos were assessed by 19 surgeons and 31 surgical residents. The overall ICC for all criteria was 0.628. Specifically, the ICC scores were 0.504 for criterion 1, 0.639 for criterion 2, and 0.719 for the criterion involving the two structures connected to the gallbladder. Consequently, only the criterion regarding clearance of the hepatocystic triangle exhibited fair agreement, whereas the other two criteria, as well as the overall scores, demonstrated good agreement. In 71% of cases, both surgeons and surgical residents scored a total score either ranging from 0 to 4 or from 5 to 6.

CONCLUSION

Compared to the gold standard, i.e., the surgeons' assessments, surgical residents are equally skilled at assessing critical view of safety (CVS) in laparoscopic cholecystectomy (LC) videos. By incorporating video-based assessments of surgical procedures into their training, residents could potentially enhance their learning pace, which may result in better clinical outcomes.

Towards a Standardization of Learning Curve Assessment in Minimally Invasive Liver Surgery

OBJECTIVE

The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting.

SUMMARY BACKGROUND DATA

MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization.

METHODS

A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery).

RESULTS

60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%).

CONCLUSIONS

This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Training and assessment for colorectal surgery and appendicectomy- a systematic review

AIM

There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach.

METHOD

A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported.

RESULTS

Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery.

CONCLUSION

This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

Variation in hospital performances after colorectal cancer surgery: A case-mix adjusted Dutch population based study

BACKGROUND

This study aimed to investigate hospital variability in postoperative mortality and anastomotic leakage (AL) after colorectal cancer surgery, as well as the association with hospital volume and teaching status.

MATERIALS AND METHODS

This nationwide population based study derived data from CRC patients who underwent a surgical resection with primary anastomosis from the Netherlands Cancer Registry between 2015 and 2020. Primary outcomes were 90-day mortality and AL for colon cancer (CC) patients, and AL for rectal cancer (RC) patients. Logistic regression modelling was used to evaluate the association between case-mix factors and hospital volume. Variability in outcomes between hospitals was analysed with Poisson regression.

RESULTS

This study included 44,101 CRC patients, comprising 35,164 CC patients, and 8937 RC patients. In the CC cohort, the unadjusted rates of AL ranged from 2.6 % to 14.4 %, and the unadjusted 90-day mortality rates ranged from 0.0 % to 6.7 %. In the RC cohort, the unadjusted rates of AL ranged from 0.0 % to 28.6 %. After case-mix adjustment, two hospitals performed significantly worse than expected regarding 90-day mortality in the CC cohort, and in both CC and RC cohorts, significant outliers were observed concerning AL. Amongst CC patients, low case volume (OR 1.26 95%CI 1.08-1.46) was significantly associated with AL.

CONCLUSION

Statistically significant variations in hospital performance were observed among Dutch hospitals after CRC surgery, but this effect could not be entirely attributed to hospitals' teaching status. Nevertheless, concentrating care has the potential to improve outcomes by enhancing individual surgical performance and optimizing care pathways.

Nationwide standardization of minimally invasive right hemicolectomy for colon cancer and development and validation of a video-based competency assessment tool (the Right study)

BACKGROUND

Substantial variation exists when performing a minimally invasive right hemicolectomy (MIRH) due to disparities in training, expertise and differences in implementation of innovations. This study aimed to achieve national consensus on an optimal and standardized MIRH technique for colon cancer and to develop and validate a video-based competency assessment tool (CAT) for MIRH.

METHOD

Statements covering all elements of MIRH were formulated. Subsequently, the Delphi technique was used to reach consensus on a standardized MIRH among 76 colorectal surgeons from 43 different centres. A CAT was developed based on the Delphi results. Nine surgeons assessed the same 12 unedited full-length videos using the CAT, allowing evaluation of the intraclass correlation coefficient (ICC).

RESULTS

After three Delphi rounds, consensus (≥80% agreement) was achieved on 23 of the 24 statements. Consensus statements included the use of low intra-abdominal pressure, detailed anatomical outline how to perform complete mesocolic excision with central vascular ligation, the creation of an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision using a wound protector. The CAT included seven consecutive steps to measure competency of the MIRH and showed high consistency among surgeons with an overall ICC of 0.923.

CONCLUSION

Nationwide consensus on a standardized and optimized technique of MIRH was reached. The CAT developed showed excellent interrater reliability. These achievements are crucial steps to an ongoing nationwide quality improvement project (the Right study).