Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA

Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy

BACKGROUND

Although transanal total mesorectal excision (TaTME) is a promising treatment for low rectal cancer, it is considered technically demanding, and the number of cases required to become proficient in TaTME remains unknown. The purpose of this study was to assess the TaTME learning curve based on the total mesorectal excision completion time.

STUDY DESIGN

This retrospective analysis comprised 128 individuals who received TaTME between September 2016 and December 2021. The cumulative sum method was used to generate the learning curve. The duration of the procedure from the beginning to the end of the circumferential rendezvous was used to define the total mesorectal excision completion time.

RESULTS

The learning curve consists of 3 phases: phase I (learning phase: cases 1 to 38), phase II (consolidation phase: cases 39 to 70), and phase III (maturing phase: cases 71 to 128). As the phases varied, both the overall operative time and total mesorectal excision completion time decreased considerably. Through the 3 phases of TaTME, intraoperative adverse events decreased, and in phase III, none occurred. Only 1 instance of local recurrence occurred during phase III, and none occurred during phase I or II.

CONCLUSIONS

After 70 operations, the surgeon could join the mastery phase of TaTME based on the total mesorectal excision completion time. After the mastering phase began, there were no intraoperative negative occurrences. From the beginning, the oncological safety could be guaranteed.

Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision

BACKGROUND

Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection.

METHODS

Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported.

RESULTS

There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without.

CONCLUSIONS

This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.

Usefulness of structured-cadaveric training for trans-anal pelvic exenteration

PURPOSE

Structured training using cadaveric simulation is useful for trans-anal surgery; however, no studies have examined the effectiveness of cadaveric training for advanced trans-anal surgery including pelvic exenteration (PE).

METHODS

Twelve colorectal surgeons attended a total of 10 cadaveric simulation training courses between 2016 and 2021 and completed a questionnaire at the end of the program. We divided 14 consecutive patients who underwent trans-anal PE between 2015 and 2021 into two groups: pre-training group and post-training group, and compared the clinico-pathological features between the groups.

RESULTS

The median length of clinical experience of the surgeons was 12 years. There was high score agreement among the surgeons that the course was useful for recognition of anatomical and layer structure, training for trans-anal total mesorectal excision and trans-anal PE, and reducing complications specific to the trans-anal approach. Compared with the pre-training group, patients in the post-training group had a higher rate of two-team surgery (77.8% vs 0%, P = .021), and shorter time to specimen removal (273 vs 423 min, P = .045).

CONCLUSIONS

Structured-cadaveric training has potential use as a technical step-up in advanced trans-anal surgery that might contribute to better short-term outcomes in the clinical setting.

Surgical Training for Transanal Total Mesorectal Excision in a Live Animal Model: A Preliminary Experience

Background: In this preliminary experience, the feasibility and effectiveness of surgical training with an animal model for transanal total mesorectal excision (TaTME) were evaluated. Methods: The training was conducted in two experimental animal laboratories in Italy authorized by the Italian Ministry of Health, using female Danish Landrace pigs under the supervision of surgeons with extensive experience in TaTME, animal laboratory training and cadaver laboratory training. The procedure was divided into separate steps, and all the participants were guided step-by-step throughout the entirety of the procedure. Results: During all the editions of the animal laboratory, all the procedures were completed with no major damage to the anatomical structures or intraoperative death of the animals. Live animal tissue is very similar to human tissue, helping trainees improve their tactile feedback. The bleeding effect improved the value of the training and taught the participants how to address this complication. The lack of mesorectal tissue in pigs compared with humans was the main difference. Animal laboratories should not be considered alternatives to cadaver laboratories but as complementary training activities due to their effectiveness and lower costs. Conclusions: Surgical training in animal models for TaTME seems to be effective and could be an opportunity to improve training alongside the use of a cadaver laboratory and proctoring.

A Transabdominal Robotic Purse-String Suture Technique for Transanal Total Mesorectal Excision

Introduction: Transanal total mesorectal excision (TaTME) is a novel technique that overcomes the problem of access to the deep pelvis during radical surgery for mid-rectal and lower rectal cancer. Although TaTME has several important steps, the creation of the distal purse-string suture following TaTME plays an important role in ensuring the integrity of the colorectal anastomosis. However, this procedure represents a major technical challenge for the surgeon. Robot-assisted surgery may make this suturing procedure easier than laparoscopic surgery because it permits intuitive wrist movements and a three-dimensional view. The aim of the present study was to investigate the usefulness of transabdominal robotic purse-string suture during anastomosis in TaTME. Methods: Twenty-seven patients, who underwent anastomosis using a single stapling technique (SST) during the TaTME of mid-rectal or lower rectal cancer, were enrolled in the study. The patients were allocated to two groups: 11 patients underwent transabdominal robotic purse-string suturing (the Robot group) and 16 patients underwent transanal purse-string suturing (the Transanal group). The characteristics and short-term surgical outcomes of the participants were compared between the two groups. Results: The Robot group tended to have a shorter purse-string suturing time (541 ± 206 seconds versus 729 ± 310 seconds; P = .07). Regarding the shape of the "donut" after SST anastomosis, in the Transanal group, 5 of the 16 participants had incomplete donuts with muscular defects and required additional suturing, whereas in the Robot group, all the participants had complete donuts (P = .04). Conclusions: Transabdominal robotic purse-string suturing may facilitate the suturing procedure and contribute to reliable anastomosis.

Two-Year Follow-Up of the First Transanal Total Mesorectal Excision (TaTME) Case Performed in Community Hospital in Hawai'i: A Case Report and Literature Review

Surgical management of rectal cancer has evolved with the advent of total mesorectal excision (TME) and neo-adjuvant treatment allowing for more sphincter-preserving proctectomies. The laparoscopic approach to TME has numerous advantages over the open approach, including faster recovery, fewer wound complications, and overall reduced morbidity. However, laparoscopic dissection around the distal portion of the rectum is particularly difficult, and thus makes achieving TME completeness and negative resection margins for low rectal tumors a challenge. Transanal TME (TaTME) is designed to overcome these difficulties. It is performed in addition to laparoscopic operation as a bottom-up approach facilitating dissection around the distal rectum. More importantly, TaTME has been shown to have the potential to improve oncological outcomes of minimally-invasive sphincter-preserving proctectomy by providing better TME specimen quality and resection margins. Although interest in TaTME has been growing worldwide, the technique is still relatively new, and adoption into routine practice may be challenging. Potential criteria for successful adoption of the TaTME technique include experience in laparoscopic rectal resection and transanal minimally-invasive surgery (TAMIS), cadaveric TaTME training, and a multidisciplinary approach to selection and management of patients with rectal cancer. Once these criteria are met, gradual and careful implementation of TaTME could be feasible. This report describes the 2-year follow-up of the first TaTME case in Hawai'i managed by a multidisciplinary oncological team in a community hospital setting.

Beyond transanal total mesorectal excision: short-term outcomes of transanal total mesorectal excision in locally advanced rectal cancer requiring resection beyond total mesorectal excision

AIM

The aim of this work was to define the role of transanal total mesorectal excision (taTME) in locally advanced rectal cancer (LARC) requiring resection beyond the mesorectal plane.

METHOD

We performed a retrospective review of the outcomes of a case series of patients undergoing taTME for rectal cancer with mesorectal fascia or adjacent organ involvement.

RESULTS

Eleven patients (six men) underwent taTME for LARC requiring resection beyond total mesorectal excision (TME). All had a restorative procedure. The transabdominal approach was open in five and minimally invasive in six cases. All patients required the resection of at least one adjacent structure, including presacral fascia, internal iliac vessels, nerve roots, uterus, vagina or seminal vesicles. Four patients required a pelvic side-wall lymph node dissection and four had intraoperative radiotherapy. In all cases, the transanal approach was useful to disconnect the rectum distally, resect adjacent organs or control the R1 risk-point. Three patients had a complication of Clavien-Dindo grade III or above (one mechanical bowel obstruction, one pelvic collection and one urine sepsis). There were no anastomotic complications. Ten patients had an R0 resection. During a median follow-up of 11 (8.6-16) months there were no local recurrences, but two patients had distant metastases. During the study period, eight patients underwent closure of their stoma whilst the remaining three have had normal anastomotic assessments and will be closed in the future.

CONCLUSION

This early series shows that implementation of taTME for resections beyond TME may be feasible and safe in a highly selected setting.

A novel surgical training simulator for transanal total mesorectal excision

BACKGROUND

The transanal total mesorectal excision (TaTME) approach for rectal cancer has been gaining popularity. Although TaTME requires specific training, the opportunity to obtain this training is limited. We developed the first dry simulator that includes some important structural landmarks to provide training that includes all the procedural steps of TaTME.

METHODS

The model was structured based on a computed tomography scan data. The simulator mimics the rectum and surrounding key anatomical structures. All material components were made of polyvinyl alcohol and stained with various colors to easily identify these anatomical structures while undergoing the training.

RESULTS

Our simulator is compact in its size and can be easily packed, stacked, and stored. The materials mimic the real one and the model allows us to perform the entire step-by-step TaTME procedures with genuine clinical devices from the attachment of operative platform to the anastomosis. We have held the course 24 times to date, with more than 200 surgeons participating not only from domestic hospitals but also from other countries. The result of the satisfaction survey from 65 participants, which was rated from 0 to 10 points, was an average score of 8.6 (± 1.4) points.

CONCLUSIONS

We present the world's first TaTME simulator and believe that it will play an important role for the safe spread of TaTME surgery.

Changing Education Paradigms: Training Transplant Fellows for High Stake Procedures

OBJECTIVE

Living kidney donation is a unique operation, as healthy patients are placed at risks inherent with major surgery without physical benefit. The ethical implications associated with any morbidity make it a high-stakes procedure. Fellowships are faced with the dilemma of optimizing fellow training in this demanding procedure while providing safe outcomes to donors. The Laparoscopic Living Donor Nephrectomy (LDN) Workshop is a resource that can provide intense instruction to help bridge the training deficit. Our aim was to examine the course's effectiveness in improving fellows' skill and confidence related to implementing LDN into future practice.

METHODS

From 2017 to 2018, 36 abdominal transplant surgery fellows participated in a 2-day workshop consisting of live surgery observation, cadaver lab, and didactic sessions. Surveys were completed precourse, postcourse, and at 3-month postcourse follow-up.

RESULTS

Preworkshop, 61% of participants reported less than 50% confidence in independent performance of LDN. Following workshop completion, 95% reported improved confidence. At 3-month follow-up, there was a 30% (p < 0.05) increase in median confidence level. Immediately following the course, 67% reported improved ability to analyze kidneys prior to donation, 74% changed the way donor candidates were evaluated, and 67% reported enhanced ability to risk stratify donors. Eighty-five percent felt it strengthened operative techniques with 70% implementing new diagnostic treatments and surgical strategies. Seventy percent of participants felt it improved their communication with colleagues and 67% had enhanced communication with patients. These trends were maintained at 3-month follow-up.

CONCLUSION

These results indicated that the LDN Workshop improves confidence and increases fellows' skillset in a high-stakes procedure. The LDN Workshop is a useful adjunct to fellowship training to optimize successful, efficient, and safe performance of a demanding procedure in a uniquely healthy donor population.

International expert consensus guidance on indications, implementation and quality measures for transanal total mesorectal excision

AIM

To provide dynamic guidance from a rigorous and up-to-date consensus on the safe implementation and application of transanal total mesorectal excision (TaTME) from an international panel of expert surgeons and educationalists supported by 14 international surgical societies.

METHOD

An adapted Delphi method and focus group discussion approach was implemented for this consensus process, with expert advice from a guidelines methodologist. Statements were generated focusing on three main topics relating to the safe implementation of TaTME: (1) indications, (2) quality and outcome measures, (3) training and implementation of TaTME.

RESULTS

Five rounds of the Delphi consensus process were completed over a 13-month period. A total of 56 surgeons experienced in TaTME and surgical education participated in this project. By Delphi round four, 80.0% or greater agreement was reached for all statements except for two, which were further reviewed during a fifth round. More complex cases that are likely to benefit from TaTME were identified, with the recommendation that they should be referred to TaTME expert centres. The most agreed upon definition of expert centres is outlined.

CONCLUSION

We have provided a current framework of best practice related to implementation of TaTME. The statements are not indefinite and will continue to be 'dynamic' and updated as new evidence emerges.

Learning Transanal Total Mesorectal Excision

A dynamic evolution is occurring in transanal surgery. Transanal techniques began with intraluminal surgical removal of rectal masses and have progressed to transanal total mesorectal excision (taTME) for rectal cancer. TaTME was first performed in 2009 by Sylla, Rattner, Delgado, and Lacy. This article documents the training pathway followed by pioneers in the taTME technique as well as consensus reports outlining the process of learning the taTME technique. A literature search was performed for taTME training, learning, and technique. Key elements in learning the taTME technique include appropriate indications, cadaver training, and outcomes reporting such as participating in a taTME registry. Consensus reports also agree on the following facets associated with improved outcomes: (1) appropriate case selection of mid and low rectal cancers, (2) prerequisite completion of an accredited training program in laparoscopic colorectal surgery and prior experience in transanal endoscopic surgery, (3) a two-team taTME approach from above and below is ideal, and (4) higher rectal cancer volume surgical practice. The unifying international recommendation for surgeons interested in learning the taTME technique conveys the following message: taTME is an advanced and complex technique that requires dedicated training and experience in TME surgery.

Transanal Surgery: A History of taTME Ancestry

Transanal total mesorectal excision (taTME) is the culmination of major developments in rectal cancer management and minimally invasive surgery. This surgical breakthrough holds great promise and excitement for the care of the rectal cancer patient. We would be remiss in discussing taTME to not acknowledge the role of transanal abdominal transanal proctosigmoidectomy, transanal endoluminal microsurgery, laparoscopy, and natural orifice transluminal endoscopic surgery that got us to this modern day explosion of the taTME approach. In this article, we detail and explain the convergence of these disparate experiences, how they culminated in the development of the taTME, and explore future directions in this field.

Transanal total mesorectal excision (TaTME): are we doing it for the right indication? An assessment of the external validity of published online video resources

BACKGROUND

The steep learning curve for safe introduction of transanal total mesorectal excision (TaTME) highlights the need for mentored training reserved for surgeons with expertise in minimally invasive colorectal surgery and transanal surgery. Video-based education in minimally invasive surgery is considered by surgical trainers as a useful teaching aid to maximize learning. This study aims to systematically assess the availability and quality of online TaTME videos.

METHODS

TaTME videos were systematically searched on YouTube.com , Colorectal diseases video channel, WebSurg.com , and AIS channel. Data collected included video characteristics, presence of supplementary educational content, patient details, indication for surgery, different steps of TaTME presented, and surgical outcomes.

RESULTS

Forty-six videos were included with a median of 92 views per month. Nineteen videos (41.3%) reported the age of the participants and 29 patients were male (63%). Body mass index (BMI) was reported in 20 videos (43.5%) with a median of 27 and it indicated obesity (BMI ≥ 30) in 2 cases only. The use of neoadjuvant treatment was reported in 8 cases (17.4%). Eighteen videos (39.1%) reported the distance of the tumor from the anal verge, with a median of 6.4 cm and in 9 out of 18 cases, the tumor distance from the anal verge was 7 cm or higher. Pathological staging was reported in 17 videos (37.0%), with 1 T1, 3 T2, 10 T3, and 3 T4 tumors.

CONCLUSIONS

There is considerable interest in TaTME videos. Lack of consensus on reporting of these videos limits the educational value of these resources, which are missing important patient details and postoperative outcomes.

Evolution of surgery for rectal cancer: Transanal total mesorectal excision～new standard or fad?～

Transanal Total Mesorectal Excision (TaTME) has recently been developed to overcome the difficulties associated with conventional laparoscopic or robotic TME. TaTME has gained popularity and becomes the center of attention among colorectal surgeons globally. The present review aims to update the literature, clarify the current status and perspectives of TaTME. Complete TaTME specimens were obtained in 85-97.1% of the case; the reported circumferential resection margin (CRM) ranged from 1.5% to 8.1%, whereas and distal resection margin (DRM) positive rates ranged from 0% to 3.2%. The conversion rate of TaTME occurred from 0 to 15%, and there was no difference between TaTME and laparoscopic or robotic TME. Intraoperative complications occurred in 5-6% of the case, which compared favorably to laparoscopic TME. The most serious intraoperative complication with this approach was urethral injury, although only small numbers were reported, which was possibly due to under-reporting. Clavien-Dindo I or II postoperative complications occurred in 22-24% of the case, and III or IV in 10-11% of the case, which did not differ between TaTME and laparoscopic or robotic TME. TaTME may be technically easier and more beneficial than laparoscopic, robotic or open TME in male patients with a narrow pelvis; in obese patients with a bulky tumor. At present two randomized controlled trials, COLOR III and GRECCAR, and comparing TaTME with laparoscopic TME are being conducted and their outcomes are awaited. TaTME is a complex procedure, but proved to be feasible, oncologically safe, and effective in difficult cases. Before this new technique is adopted, proper training with Proctor/mentorship is strongly advised. Careful case selection and audit of data are mandatory.

Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study

OBJECTIVE

To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes.

BACKGROUND

Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown.

METHODS

A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated.

RESULTS

Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction.

CONCLUSIONS

Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.

The value of force and torque measurements in transanal total mesorectal excision (TaTME)

Background

Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing.

Methods

A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling.

Results

Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum.

Conclusions

Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.

Transanal TME: new standard or fad?

Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.

Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma

BACKGROUND

Early observational data suggest that this approach is safe and feasible, but it is technically challenging and the learning curve has not yet been determined. The objective of this study was to determine the number of cases required achieve proficiency in transanal total mesorectal excision (TA-TME) for rectal adenocarcinoma.

METHODS

All TA-TME cases performed from 03/2012-01/2017 at a single high-volume tertiary care institution for rectal adenocarcinoma were included. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency, defined as high-quality TME (complete or near-complete mesorectal envelope, negative distal (DRM), and circumferential resection (> 1 mm; CRM) margin). The acceptable and unacceptable rates of good quality TME were defined based on the incidence of high-quality TME in laparoscopic (unacceptable rate = 81.7%) and open (acceptable rate = 86.9%) arms of the ACOSOG Z6051 trial.

RESULTS

A total of 87 consecutive cases were included with mean tumor height 4.8 cm (SD 2.7) and 80% (70/87) received neoadjuvant chemoradiation. Post-operative morbidity occurred in 44% (38/87) of cases, including 21% (18/87) readmissions. Median length of stay was 4 days [IQR 3-8]. A good quality TME was performed in 95% (83/87) of cases including 98% (85/87) negative CRM, 99% (86/87) negative DRM, and 99% (86/87) complete or near-complete mesorectal envelope. CUSUM analysis reported that the good quality TME rate reaches an acceptable rate after 51 cases overall, and 45 cases if abdominoperineal resections are excluded.

CONCLUSION

TA-TME is a complex technique that requires a minimum of 45-51 cases to reach an acceptable incidence of high-quality TME and lower operative duration.

Using cadaveric simulation to introduce the concept and skills required to start performing transanal total mesorectal excision

AIM

The aim was to document the outcomes of surgeons attending a cadaveric simulation course designed to provide an introduction to transanal total mesorectal excision (TaTME).

METHOD

This was a prospective observational study documenting the outcomes from classroom and wet lab activities. Follow-up questionnaires were used to monitor clinical activity after the course.

RESULTS

Outcomes of 65 delegates from 12 different countries attending seven cadaveric simulation courses are described. Median time to insert and close the rectal purse-string was 15 min (range 7-50 min) and median time to complete the transanal mesorectal dissection was 105 min (range 60-260 min). Objective assessment of specimen quality showed that 42% of specimens were complete, 47% nearly complete and 11% were incomplete. Failure of the intraluminal rectal purse-string was the most common difficulty encountered. Within 6 months of attending the course, nearly half (26/55; 47%) of the surgeons who responded had performed between 1 and 13 TaTMEs. Only 8/26 (31%) of the surgeons had arranged mentoring for their first case.

CONCLUSION

This training model provides high levels of trainee satisfaction and the knowledge and technical skills to enable them to start performing TaTME. There is still work to do to provide adequate supervision and mentorship for surgeons early on their learning curve that is essential for the safe introduction of this new technique.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

Recent updates in the surgical treatment of colorectal cancer

Because of recent advances in medical technology and new findings of clinical trials, treatment options for colorectal cancer are evolutionally changing, even in the last few years. Therefore, we need to update the treatment options and strategies so that patients can receive optimal and tailored treatment. The present review aimed to elucidate the recent global trends and update the surgical treatment strategies in colorectal cancer by citing the literature published in the last 2 years, namely 2016 and 2017. Although laparoscopic surgery is still considered the most common approach for the treatment of colorectal cancer, new surgical technologies such as transanal total mesorectal excision, robotic surgery, and laparoscopic lateral pelvic lymph node dissection are emerging. However, with the recent evidence, superiority of the laparoscopic approach to the open approach for rectal cancer seems to be controversial. Surgeons should notice the risk of adverse outcomes associated with unfounded and uncontrolled use of these novel techniques. Many promising results are accumulating in preoperative and postoperative treatment including chemotherapy, chemoradiotherapy, and targeted therapy. Development of new biomarkers seems to be essential for further improvement in the treatment outcomes of colorectal cancer patients.

Improved urethral fluorescence during low rectal surgery: a new dye and a new method

BACKGROUND

The aim of this study was to demonstrate highlighting of the urethra during surgery through the use of two different methods: a new near-infrared fluorophore IRDye800BK, and indocyanine green (ICG) mixed with silicone.

METHODS

Male cadavers from the department of anatomy at the University of Oxford were used to visualise the urethra during near-infrared fluorescence excitation. To assess IRDye800BK, a perineal incision was utilised after infiltrating the urethra directly with an IRDye800BK solution mixed with Instillagel. ICG-silicone was assessed when the urethra was purposely exposed as part of a simulated transanal total mesorectal dissection. ICG was previously mixed with ethanol and silicone and left to set in a Foley catheter. Fluorescence was visualised using an in-house manufactured fluorescence-enabled laparoscopic system.

RESULTS

IRDye800BK demonstrated excellent penetration and visualisation of the urethra under fluorescence at an estimated tissue depth of 2 cm. An ICG-silicone catheter demonstrated excellent fluorescence without leaving any residual solution behind in the urethra after its removal.

CONCLUSIONS

The newly described ICG-silicone method opens up the possibility of new technologies in this area of fluorescence guided surgery. IRDye800BK is a promising alternative to ICG in visualising the urethra using fluorescence imaging. Its greater depth of penetration may allow earlier detection of the urethra during surgery and prevent wrong plane surgery sooner.

An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (taTME)

AIM

To evaluate the use of a pathway for the introduction of transanal total mesorectal excision (taTME) into Australia and New Zealand.

METHOD

A pathway for surgeons with an appropriate level of specialist training and baseline skill set was initiated amongst colorectal surgeons; it includes an intensive course, a series of proctored cases and ongoing contribution to audit. Data were collected for patients who had taTME, for benign and malignant conditions, undertaken by the initial adopters of the technique.

RESULTS

A total of 133 taTME procedures were performed following the introduction of a training pathway in March 2015. The indication was rectal cancer in 84% of cases. There was one technique-specific visceral injury, which occurred prior to that surgeon completing the pathway. There were no cases of postoperative mortality; morbidity occurred in 27.1%. The distal resection margin was clear in all cases of rectal cancer, and the circumferential resection margin was positive in two cases. An intact or nearly intact total mesorectal excision was obtained in more than 98% of cases.

CONCLUSION

This study demonstrates the safe and controlled introduction of a new surgical technique in a defined surgeon population with the use of a pathway for training. The authors recommend a similar pathway to facilitate the introduction of taTME to colorectal surgical practice.

Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)

BACKGROUND

The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME.

METHODS

A consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert's consensus to draw an agreement on essential elements of the curriculum.

RESULTS

Appropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and accreditation in laparoscopic colorectal surgery, with prior experience in transanal surgery. Ideally, two surgeons should undergo training together in centres with high volume for rectal cancer surgery. Mentorship and multidisciplinary training were the two most important aspects of the curriculum, which should also include online modules and simulated training for purse-string suturing. Mentors should have performed at least 20 TaTME cases and be experienced in laparoscopic training. Reviewing the specimens' quality, clinical outcome data and entering data into a registry were recommended. Assessment should be an integral part of the curriculum using Global Assessment Scales, as formative assessment to promote learning and competency assessment tool as summative assessment.

CONCLUSIONS

A detailed framework for a structured TaTME training curriculum has been proposed. It encompasses various training modalities and assessment, as well as having the potential to provide quality control and future research initiatives for this novel technique.