Conventional Laparoscopic vs Robotic Training: Which is Better for Naive Users? A Randomized Prospective Crossover Study

Transferability of the robot assisted and laparoscopic suturing learning curves

Robot assisted surgery (RAS) is increasingly used, and besides conventional minimally invasive surgery (cMIS) surgeons are challenged to learn an increased array of skills. This study aimed to assess the influence of both learning curves on each other. A prospective randomized crossover study was performed. Participants without cMIS or RAS experience (Groups 1 and 2), and cMIS experienced, (Group 3) were recruited. Three suturing tasks (intracorporal suturing, tilted plane and anastomosis needle transfer) were performed on the EoSim cMIS simulator or RobotiX RAS simulator up to twenty repetitions. Subsequently, Groups 1 and 2 performed the tasks on the other modality. Outcomes were simulator parameters, validated composite and pass/fail scores. In total forty-three participants were recruited. Overall RAS suturing was better in Group 1 (cMIS followed by RAS tasks) and 3 (RAS tasks) versus Group 2 (RAS followed by cMIS tasks) for time (163 s and 157 s versus 193 s p = 0.004, p = 0.001) and composite scores (92/100 and 91/100 versus 89/100 p = 0.008, p = 0.020). The cMIS suturing was better for Group 2 versus 1 (time 287 s versus 349 s p = 0.005, composite score 96/100 versus 94/100 p = 0.002). Significant differences from the RAS suturing pass/fail were reached earlier by Group 3, followed by Groups 1 and 2 (repetition six, nine and twelve). In cMIS suturing Group 2 reached significant differences from the pass/fail earlier than Group 1 (repetition four versus six). Transferability of skills was shown for cMIS and RAS, indicating that suturing experience on cMIS or RAS is beneficial in learning either approach.

Laparoscopic but not open surgical skills can be transferred to robot-assisted surgery: A systematic review and meta-analysis

BACKGROUND

With an increase in robot-assisted surgery across all specialties, adequate training and credentialing strategies need to be identified to ensure patients safety. The meta-analysis assesses the transferability of technical surgical skills between laparoscopic surgery, open surgery, and robot-assisted surgery.

DESIGN

A systematic search was conducted in Medline, Cochrane Central Register of Controlled Trials, and Web of Science. Outcomes were categorized into time, process, product, and composite outcome measures and pooled separately using Hedges'g (standardized mean difference [SMD]). Subgroup analyses were performed to assess the effect of study design, virtual reality platforms and task difficulty.

RESULTS

Out of 14,120 screened studies, 30 were included in the qualitative synthesis and 26 in the quantitative synthesis. Technical surgical skill transfer was demonstrated from laparoscopic to robot-assisted surgery (composite: SMD 0.40, 95%-confidence interval [CI] [0.19; 0.62], time: SMD 0.62, CI [0.33; 0.91]) and vice versa (composite: SMD 0.66, CI [0.33; 0.99], time [basic skills]: SMD 0.36, CI [0.01; 0.72]). No skill transfer was seen from open to robot-assisted surgery with limited available data.

CONCLUSION

Technical surgical skills can be transferred from laparoscopic to robot-assisted surgery and vice versa. Robot-assisted and laparoscopic surgical skills training and credentialing should not be regarded separately, but a reasonable combination could shorten overall training times and increase efficiency. Previous experience in open surgery should not be considered as an imperative prerequisite for training in robot-assisted surgery. Recommendations for studies assessing skill transfer are proposed to increase comparability and significance of future studies.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018104507.

Adapting to a Robotic Era: The Transferability of Open and Laparoscopic Skills to Robotic Surgery

BACKGROUND

The learning curve of robotic surgical skills is poorly understood. There is a lack of data on the transferability of skills from open and laparoscopic training to robotic surgery. In this retrospective cohort study, we investigated the impact of training acquired during intern year on the development of robotic skills in general surgery residents, prior to formal robotic training.

METHODS

Between 2019 and 2021, novice general surgery residents underwent robotic skill assessment using 3 validated inanimate drills before starting intern year. After completing basic open and laparoscopic proficiency-based curricula, they completed an identical robotic skill assessment at the end of intern year. Pre and post intern year robotic performances were recorded and analyzed by 2 blinded graders. Video-based assessment included completion time, errors, and the modified Objective Structured Assessment of Technical Skills (mOSATS) score.

RESULTS

The total time needed to complete all 3 robotic drills decreased from a mean of 26 to 17 minutes after intern year (p < 0.001). The number of errors decreased from a mean of 2.16 to 0.56 errors per subject (p < 0.001). The aggregated mOSATS score increased by an average of 41% (p < 0.001), with a greater increase in technical skill domains compared to the knowledge-based domain. The interrater intraclass correlation coefficient was 0.91.

CONCLUSIONS

Baseline robotic surgical skills are limited without formal training. Our findings suggest that acquiring basic open and laparoscopic skills, such as knot tying, needle driving, and tissue handling results in improved performance on the robotic platform, prior to formal robotic training. Therefore, requiring trainees to complete fundamental open and laparoscopic training prior to robotic training may be an efficient and effective strategy within a surgical residency curriculum.

Transfer of skills between laparoscopic and robot-assisted surgery: a systematic review

BACKGROUND

Robot-assisted surgery is today well-implemented in many surgical specialties, but requires another skill set than laparoscopy. Most often, robot-assisted surgery is considered add-on to laparoscopic skills but very little is known about the transfer of skills. The aim of the study was to examine to what extent surgical skills are transferable between laparoscopic and robot-assisted surgery.

METHODS

A systematic search was conducted in three databases (Ovid Medline, Embase, and Web of Science). Studies investigating transfer of skills between laparoscopy and robot-assisted surgery in either a phantom-based, simulation-based, animal model, or clinical setting were eligible for inclusion. Quality assessment was done using the Medical education research study quality instrument and educational New Ottawa Scale.

RESULTS

Of 15,610 studies identified, 89 studies continued to full-text reading, and 37 studies were included. Four studies were found non-comparable and were left out of the results for the primary outcome. All 33 studies explored transfer from laparoscopy to robot-assisted surgery and 17 found a positive transfer whereas 15 did not. Only 11 studies explored transfer from robot-assisted surgery to laparoscopy, of which only three found a positive transfer.

CONCLUSION

An almost equal number of publications found a positive transfer and no transfer from laparoscopic to robot-assisted surgery. Fewer studies explored the transfer from robot-assisted surgery to laparoscopy. Very little evidence supports that surgeons trained solely in robot-assisted surgery can perform laparoscopy. This must be considered in future training programs as robot-assisted surgery is expected to become the first-in-line modality for many future surgeons.

Crossover-effects in technical skills between laparoscopy and robot-assisted surgery

INTRODUCTION

Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery.

METHODS

An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated.

RESULTS

A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery.

CONCLUSION

The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.

Transfer of open and laparoscopic skills to robotic surgery: a systematic review

Due to its advantages over open surgery and conventional laparoscopy, uptake of robot-assisted surgery has rapidly increased. It is important to know whether the existing open or laparoscopic skills of robotic novices shorten the robotic surgery learning curve, potentially reducing the amount of training required. This systematic review aims to assess psychomotor skill transfer to the robot in clinical and simulated settings. PubMed, EMBASE, Cochrane Library and Scopus databases were systematically searched in accordance with PRISMA guidelines from inception to August 2021 alongside website searching and citation chaining. Article screening, data extraction and quality assessment were undertaken by two independent reviewers. Outcomes included simulator performance metrics or in the case of clinical studies, peri- and post-operative metrics. Twenty-nine studies met the eligibility criteria. All studies were judged to be at high or moderate overall risk of bias. Results were narratively synthesised due to heterogeneity in study designs and outcome measures. Two of the three studies assessing open surgical skill transfer found evidence of successful skill transfer while nine of twenty-seven studies evaluating laparoscopic skill transfer found no evidence. Skill transfer from both modalities is most apparent when advanced robotic tasks are performed in the initial phase of the learning curve but quality and methodological limitations of the existing literature prevent definitive conclusions. The impact of incorporating laparoscopic simulation into robotic training curricula and on the cost effectiveness of training should be investigated.

Ensuring safety and feasibility for resection of pediatric benign ovarian tumors by single-port robot-assisted laparoscopic surgery using the da Vinci Xi system

Background

Single-port robot-assisted laparoscopic surgery (S-RALS) is rarely applied in pediatric surgery. There is still no study on the application of S-RALS for resection of pediatric benign ovarian tumors. The current study aimed to investigate the safety and feasibility of S-RALS for resection of pediatric benign ovarian tumors using the da Vinci Xi system.

Methods

The clinical data of three patients who underwent S-RALS for resection of benign ovarian tumors in the Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University from May 2020 to September 2021 were retrospectively analyzed. The mean age of these children was 7.9 years (5.8–9.3 years). One was a case of bilateral ovarian tumors, and the other two were cases of right ovarian tumors.

Results

All three patients successfully underwent the resection of ovarian tumors through S-RALS without conversion to laparotomy. The average operation time was 180 min (118–231 min). The average amount of blood loss was 20 ml (10–35 ml). No drainage tube was placed. All postoperative pathological types of ovarian tumors were mature cystic teratomas in the three cases. All patients started a liquid diet 2 h after surgery. The average length of postoperative hospital stay was 4.7 days (3–7 days). No tumor recurred, no surgical site hernia occurred, and the wound healed very well with a cosmetic scar in the lower umbilical crease during the postoperative follow-up for 6–18 months.

Conclusion

S-RALS has the advantages of less surgical trauma, quick postoperative recovery, and a cosmetic scar in the lower umbilical crease. It is safe, effective, and feasible for pediatric benign ovarian tumors.

Transference of skills in robotic vs. laparoscopic simulation: a randomized controlled trial

BACKGROUND

Elucidating how robotic skills are best obtained will enable surgeons to best develop future robotic training programs. We perform a randomized controlled trial to assess the performance of robotic compared to laparoscopic surgery, transference of pre-existing skills between the two modalities, and to assess the learning curve between the two using novice medical students.

METHODS

Forty students were randomized into either Group A or B. Students practiced and were tested on a peg transfer task in either a laparoscopic simulator (LS) and robotic simulator (RS) in a pre-defined order. Performance, transference of skills and learning curve were assessed for each modality. Additionally, a fatigue questionnaire was issued.

RESULTS

There was no significant difference between overall laparoscopic scores (219 ± 19) and robotic scores (227 ± 23) (p = 0.065). Prior laparoscopic skills performed significantly better on robotic testing (236 ± 12) than without laparoscopic skills (216 ± 28) (p = 0.008). There was no significant difference in scores between students with prior robotic skills (223 ± 16) than without robotic skills (215 ± 22) (p = 0.162). Students reported no difference in fatigue between RS and LS. The learning curve plateaus at similar times between both modalities.

CONCLUSION

Novice medical students with laparoscopic skills performed better on a RS test than students without laparoscopic training, suggesting a transference of skills from laparoscopic to robotic surgery. These results suggest laparoscopic training may be sufficient in general surgery residencies as the skills transfer to robotic if used post-residency.

Low versus high level of physical resemblance in simulation for the acquisition of basic surgical skill: a meta-analysis

Background

Many studies explored the use of simulation in basic surgical education, with a variety of devices, contexts and outcomes, with sometimes contradictory results.

Objectives

The objectives of this meta-analysis were to focus the effect that the level of physical resemblance in a simulation has on the development of basic surgical skill in undergraduate medical students and to provide a foundation for the design and implementation of a simulation, with respect to its effectiveness and alignment with the learning outcomes.

Study selection

We searched PubMed and Scopus database for comparative randomised studies between simulations with a different level of resemblance. The result was synthesised as the standardised mean difference, under a random effect model.

Findings

We selected 12 out of 2091 retrieved studies, reporting on 373 undergraduate students (mean of subjects 15.54±6.89). The outcomes were the performance of simple skills and the time to complete a task. Two studies reported a scoring system; seven studies reported time for a task; and three studies reported both. The total number of measures included in the meta-analysis was 456 for score and 504 for time. The pooled effect size did not show any significant advantage in a simulation of a high level of physical resemblance over a lower level, both for the scoring system (−0.19, 95% CI −0.44 to 0.06) and for time (−0.14, 95% CI −0.54 to 0.27).

Conclusion

Simulations with a low level of physical resemblance showed the same effect as the simulation using a higher level of resemblance on the development of basic surgical skills in undergraduate students.

Medical student experience with robot-assisted surgery after limited laparoscopy exposure

The purpose of the study was to evaluate the objective and subjective experience of medical students completing robotic surgery tasks after limited laparoscopy exposure. Twenty-three medical students without previous laparoscopy and robotic surgery experience self-enrolled into 0 min (n = 11), 20 min (n = 6), and 40 min (n = 6) laparoscopy training groups. Subjects completed rope passing and ball placement tasks on a laparoscopy trainer before repeating similar tasks on the Senhance Surgical System, a robot-assisted digital laparoscopy device. Videos were recorded to evaluate objective measures including time, completion rate, clutch use, out of view instruments, ball drops, and manual adjustments. The NASA-TLX survey was administered to assess subjective experience using workload and task demand measures. There were no statistically significant differences in objective performance between the groups (p > 0.05). Subjects who completed laparoscopy training reported higher workloads, but these differences were not statistically significant (p > 0.05). NASA-TLX workload was correlated with time performance on Pearson and Spearman tests (r = 0.623, rho = 0.681, p < 0.01). Initial experience of medical students with robot-assisted surgery did not differ significantly after limited laparoscopy exposure.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center

Objective

The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP).

Methods

This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy.

Results

A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217).

Conclusion

Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

Transition effects from laparocscopic to robotic surgery skills in small cavities

Conventional laparoscopic surgery (LS) is being challenged by the ever-increasing use of robotic surgery (RS) to perform reconstructive procedures. The purpose of this study was to assess the acquisition of skills in both techniques and the potential transfer of skills from one technique to the other when restricted spaces are involved. A preclinical randomized crossover study design was implemented. Twelve subjects performed two different reproducible drill procedures: "Thread the Ring" (TR) and "Transfer the Plot" (TP). To assess surgical proficiency in confined workspaces, these exercises were performed with LS and RS technology in a pediatric laparoscopic surgery (PLS) simulator. Each performance was recorded and evaluated by two reviewers using objective structured assessment of technical skills (OSATS). The times to complete the TP and the TR procedure were significantly shorter with RS compared to LS (64 s vs. 319 s; p < 0.0001 for both TP and TR). A significant transfer effect of skills between LS and RS was noted for the TP exercise (p = 0.006). The percentage improvement was greater overall with LS, meaning a higher number of trials were required to adequately master the procedure. This study demonstrated that RS performed significantly better compared to LS on pediatric simulation devices. A transfer effect was identified from LS to RS exclusively. The learning curves showed that progression was definitely longer with LS. These results, indicate that novice surgeons should be encouraged to persist with learning LS, and they support the use of a pediatric robotic simulation device.

Robotic-assisted resection of ovarian tumors in children: A case report and review of literature

BACKGROUND

Ovarian tumors are common gynecological diseases in children, and the most commonly seen ovarian tumors are germ cell tumors. Robotic surgery is the new access for children ovarian tumors.

CASE SUMMARY

From June to October 2017, 4 children with ovarian tumors were admitted and treated in the Department of Pediatric Surgery of People’s Liberation Army General Hospital. The mean age, height, and weight of these patients were 7.5 (1-13) years old, 123.75 (71-164) cm, and 36.8 (8.5-69.5) kg, respectively. Robotic-assisted resection of ovarian tumors was performed for all 4 patients. The 3-port approach was used for robotic manipulation. The surgical procedures were as follows. After creation of the pneumoperitoneum, the robotic scope was placed to explore and find the left ovarian tumor. The trocars for robotic arms 1 and 2 were placed at the sites to the lower right and left of the port of the scope. The tumor capsule in the fallopian tube was incised, and the tumor was completely stripped by an electric hook along the junction of the tumor and the capsule. The resected tumor was completely removed using an endobag. The average docking time of the robotic system was 18.5 min, the average operative time was 120 min, and the average blood loss was 20 mL. No drainage tube was placed except in one patient with a mucinous tumor of the ovary. No fever, pelvic fluid, or intestinal obstruction was reported after surgery. No antibiotics were used during the perioperative period, and the average length of hospital stay after surgery was 3 d.

CONCLUSION

Robotic-assisted resection of ovarian tumors is a simple, safe, and effective surgical procedure for selected patients.

Virtual reality simulator versus box-trainer to teach minimally invasive procedures: A meta-analysis

BACKGROUND

To evaluate the effectiveness of virtual reality simulator (VRS) training compared to box-trainer training (BT) for learning outcomes in minimally invasive surgery (MIS) techniques.

MATERIALS AND METHODS

A systematic review of the literature was performed using CENTRAL, MEDLINE, EMBASE, Scopus, CINAHL, LILACS. The primary outcomes were time to perform MIS and performance score in MIS. After being selected, the articles were evaluated for methodological quality and risk of bias. The results were evaluated for quality of evidence and meta-analysis was performed.

RESULTS

20 randomized clinical trials were included in the qualitative analysis and 14 were used in the meta-analysis. VRS training was more efficient than BT training (P < 0.00001, 95% CI: 35.08 to -25.01) when evaluating participant time needed to complete the peg task. In descriptive analysis, VRS training was better than BT training in participant performance score to perform MIS. There was no statistical difference in the meta-analysis in the time needed to perform surgery, time to complete basic or advanced tasks and performance score for basic or advanced tasks.

CONCLUSIONS

VRS training was better than BT training in participant performance scores when performing MIS and in the time needed to complete the basic task of peg transfer. In all other outcomes, regardless of the student's level of experience or type of activity, the two forms of training were equivalent.

Structured training program in colorectal surgery: the robotic surgeon as a new paradigm

BACKGROUND

One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model.

METHODS

Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP.

RESULTS

The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21.

CONCLUSIONS

A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.

Robotic Right Colectomy for Colon Cancer: Comparison of Outcomes from a Single Institution with the ACS-NSQIP Database

BACKGROUND

Robotic surgery has increased in recent years for the treatment of colorectal cancer; however, it is not yet the standard of care. This study aims to compare the 30-day outcomes after robotic colectomy for right-sided colon cancer from our institution with those from a national dataset, the targeted colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

Patients undergoing elective, robotic, right colon resection for stage I, II, and III colon cancer were identified within the targeted colectomy ACS-NSQIP database from 2012 to 2014. Patients meeting the same criteria were identified within a prospectively maintained institutional database from 2009 to 2015. Univariate analyses using chi-square tests and Student's t-tests were done where appropriate to compare baseline characteristics and outcomes between the two groups.

RESULTS

Patients at our institution had a significantly higher average number of lymph nodes retrieved (24.4 versus 20.1, P = .046). There was no statistically significant difference between the two groups regarding the incidence of wound infections, anastomotic leaks, blood transfusions, unplanned return to the operating room, or prolonged length of hospital stay. There were no 30-day mortalities at our institution and only one in the ACS-NSQIP database.

CONCLUSIONS

Our institutional experience with robotic right colon resection is equivalent to that of a national sample. This study demonstrates the safety of performing robotic right hemicolectomy for the treatment of colon cancer.

Implementing assessments of robot-assisted technical skill in urological education: a systematic review and synthesis of the validity evidence

OBJECTIVES

To systematically review and synthesise the validity evidence supporting intraoperative and simulation-based assessments of technical skill in urological robot-assisted surgery (RAS), and make evidence-based recommendations for the implementation of these assessments in urological training.

MATERIALS AND METHODS

A literature search of the Medline, PsycINFO and Embase databases was performed. Articles using technical skill and simulation-based assessments in RAS were abstracted. Only studies involving urology trainees or faculty were included in the final analysis.

RESULTS

Multiple tools for the assessment of technical robotic skill have been published, with mixed sources of validity evidence to support their use. These evaluations have been used in both the ex vivo and in vivo settings. Performance evaluations range from global rating scales to psychometrics, and assessments are carried out through automation, expert analysts, and crowdsourcing.

CONCLUSION

There have been rapid expansions in approaches to RAS technical skills assessment, both in simulated and clinical settings. Alternative approaches to assessment in RAS, such as crowdsourcing and psychometrics, remain under investigation. Evidence to support the use of these metrics in high-stakes decisions is likely insufficient at present.

Participation of Colon and Rectal Fellows in Robotic Rectal Cancer Surgery: Effect on Surgical Outcomes

OBJECTIVES

To determine whether involvement of colon and rectal fellows has an effect on short-term surgical and oncological outcomes in robotic rectal cancer surgery.

PATIENTS AND METHODS

From a dataset of 263 robotic-assisted rectal cancer operations, 114 case-matched patients over a 5-year period (January 2010-December 2015) were included in the study. Patients who underwent resection with and without fellow involvement were compared. Cases were matched according to age, body mass index, neoadjuvant therapy, and tumor location. Intraoperative, postoperative, and pathological outcomes were compared between the 2 groups.

RESULTS

There was no difference in tumor grade, type of surgical procedure, presence of an anastomosis, or diverting stoma between groups. In addition, there was no difference in the incidence of intraoperative or postoperative complications between the 2 groups. Estimated blood loss was higher in the fellow group compared to the consultant group (mean difference of 70mL, p = 0.007). For pathological outcomes, there was no difference in surrogate oncological quality indicators, specifically margin positivity and lymph node yield, between the 2 groups. Furthermore, fellow involvement did not adversely affect operative time.

CONCLUSION

This study demonstrates that equivalent short-term surgical and oncological outcomes can be achieved with colorectal fellow participation in the field of robotic-assisted rectal cancer surgery.

Minimally Invasive Surgery to Treat Gynecological Cancer: Conventional Laparoscopy and/or Robot-Assisted Surgery

Robotic-assisted surgery is a technological advancement derived from conventional laparoscopy, which facilitates the application of minimally invasive techniques for complex operations in the field of gynecological oncology. However, its introduction in gynecological cancer has been scarce in most hospitals worldwide. Most publications on robotic surgery are still retrospective or descriptive in nature. Some studies compare robotic-assisted laparoscopy with open procedures, which is a questionable analysis, because the advantages of minimally invasive surgery have been already well established. Robotic surgery should be directly compared with conventional laparoscopy to determine whether its additional direct and indirect costs are in accordance with some improvements within patient clinical outcomes. On the other hand, the role of robotic-assisted surgery in allowing more patients to receive the benefits of the minimally invasive approach should also be considered. The objective of this article was, therefore, to review the literature regarding the role of conventional and robotic-assisted laparoscopy to treat women with gynecologic cancer.

Evidence for the use of robotically assisted surgery in gynecologic cancers

PURPOSE OF REVIEW

Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology.

RECENT FINDINGS

The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green.

SUMMARY

The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.

Effect of visual feedback during laparoscopic basic training using a box trainer with a transparent top

Laparoscopic surgical training using a box trainer facilitates mastery of laparoscopic surgery. Few studies have investigated whether visualizing the surgical field in the box trainer improves performance of laparoscopic surgical procedures during laparoscopic training. An original box trainer equipped with a transparent top made of mesh covered with a latticed structure was developed and used for evaluation of novices during laparoscopic training. Three tasks (levels 1 to 3) involving organ handling while setting the surgical field were arranged to evaluate the efficacy of training. Forty-five students were divided into three groups: group A, students without practical training; group B, students trained using the covered box trainer; and group C, students trained using the transparent box trainer. Completion time of each task before and after training was compared. Training significantly reduced the operating time, with a significant difference between the level 1 task and the levels 2 (P<.001) and 3 (P<.0001) tasks. There was no significant difference in operating time between the levels 2 and 3 tasks. Overall time reduction rate in group C was significantly shorter than that in group A, but not in group B. The time reduction rate for the level 3 task was lowest in group C, with a statistically significant difference existing in group A (P<.001). Visual feedback during surgery through the transparent top of the laparoscopic box trainer helped reduce the learning time required to carry out laparoscopic surgery.

Robot-assisted Surgery in Gynecologic Cancers

Robotic-assisted surgery is a technological advancement that facilitates the application of minimally invasive techniques for complex operations in gynecologic oncology. The objective of this article was to review the literature regarding the role of robotic-assisted surgery to treat women with gynecologic cancers. The majority of publications on robotic surgery are still retrospective or descriptive in nature; however, the data for managing patients with a robotic-assisted approach show comparable, and at times improved, outcomes compared with both laparoscopy (2-dimensional) and laparotomy approaches. Robotic-assisted surgery has been used for patients with endometrial cancer and resulted in the increased use of minimally invasive surgery with improved outcomes compared with laparotomy and partially with laparoscopy. This has been shown in large cohorts of patients as well as in obese patients in whom the complication rates have significantly decreased. For early cervical cancer, robotic radical hysterectomy seems to be safe and feasible and to be preferable to laparotomy with seemingly comparable oncologic outcomes. Robotic-assisted surgery and conventional laparoscopy to stage women with early-stage ovarian cancer seem to have similar surgical and oncologic outcomes, with a shorter learning curve for robotic-assisted surgery. However, robotic-assisted surgery appears to be more expensive than laparotomy and traditional laparoscopy. In conclusion, robotic-assisted surgery appears to facilitate the surgical approach for complex operations to treat women with gynecologic cancers. Although randomized controlled trials are lacking to further elucidate the equivalence of robot-assisted surgery with conventional methods in terms of oncologic outcome and patients' quality of life, the technology appears to be safe and effective and could offer a minimally invasive approach to a much larger group of patients.