Abstract
Background
The value of virtual reality (VR) simulators for robot-assisted surgery (RAS) for skill assessment and training of surgeons has not been established. This systematic review and ...meta-analysis aimed to identify evidence on transferability of surgical skills acquired on robotic VR simulators to the operating room and the predictive value of robotic VR simulator performance for intraoperative performance.
Methods
MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science were searched systematically. Risk of bias was assessed using the Medical Education Research Study Quality Instrument and the Newcastle–Ottawa Scale for Education. Correlation coefficients were chosen as effect measure and pooled using the inverse-variance weighting approach. A random-effects model was applied to estimate the summary effect.
Results
A total of 14 131 potential articles were identified; there were eight studies eligible for qualitative and three for quantitative analysis. Three of four studies demonstrated transfer of surgical skills from robotic VR simulators to the operating room measured by time and technical surgical performance. Two of three studies found significant positive correlations between robotic VR simulator performance and intraoperative technical surgical performance; quantitative analysis revealed a positive combined correlation (r = 0.67, 95 per cent c.i. 0.22 to 0.88).
Conclusion
Technical surgical skills acquired through robotic VR simulator training can be transferred to the operating room, and operating room performance seems to be predictable by robotic VR simulator performance. VR training can therefore be justified before operating on patients.
Graphical Abstract
Graphical Abstract
This systematic review and meta-analysis presents current evidence on transferability of surgical skills acquired on robotic VR simulators to the real operating room, and on the predictability of intraoperative performance by robotic VR simulator performances. The limited data currently available support the use of robotic VR simulators for surgical skill acquisition and assessment.
This systematic review and meta-analysis presents current evidence on transferability of surgical skills acquired on robotic VR simulators to the real operating room, and on the predictability of intraoperative performance by robotic VR simulator performances. The limited data currently available support the use of robotic VR simulators for surgical skill acquisition and assessment.
Surgical resection is crucial for curative treatment of rectal cancer. Through multidisciplinary treatment, including radiochemotherapy and total mesorectal excision, survival has improved ...substantially. Consequently, more patients have to deal with side effects of treatment. The most recently introduced surgical technique is robotic-assisted surgery (RAS) which seems equally effective in terms of oncological control compared to laparoscopy. However, RAS enables further advantages which maximize the precision of surgery, thus providing better functional outcomes such as sexual function or contience without compromising oncological results. This review was done according to the PRISMA and AMSTAR-II guidelines and registered with PROSPERO (CRD42018104519). The search was planned with PICO criteria and conducted on Medline, Web of Science and CENTRAL. All screening steps were performed by two independent reviewers. Inclusion criteria were original, comparative studies for laparoscopy vs. RAS for rectal cancer and reporting of functional outcomes. Quality was assessed with the Newcastle–Ottawa scale. The search retrieved 9703 hits, of which 51 studies with 24,319 patients were included. There was a lower rate of urinary retention (non-RCTs: Odds ratio (OR) 95% Confidence Interval (CI) 0.65 0.46, 0.92; RCTs: ORCI 1.290.08, 21.47), ileus (non-RCTs: ORCI 0.860.75, 0.98; RCTs: ORCI 0.800.33, 1.93), less urinary symptoms (non-RCTs mean difference (MD) CI − 0.60 − 1.17, − 0.03; RCTs: − 1.37 − 4.18, 1.44), and higher quality of life for RAS (only non-RCTs: MDCI: 2.99 2.02, 3.95). No significant differences were found for sexual function (non-RCTs: standardized MDCI: 0.46− 0.13, 1.04; RCTs: SMDCI: 0.09− 0.14, 0.31). The current meta-analysis suggests potential benefits for RAS over laparoscopy in terms of functional outcomes after rectal cancer resection. The current evidence is limited due to non-randomized controlled trials and reporting of functional outcomes as secondary endpoints.
Objective
To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT).
Background
Treatment of INP has ...changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies.
Methods
We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033
Results
Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval CI 0.31 0.10, 0.98) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR CI 0.31 0.10, 0.93), and pancreatic fistulae (OR CI 0.09 0.03, 0.28). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference CI − 7.86 days − 14.49, − 1.22). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate.
Conclusion
There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.
Plasma protein factor XII (FXII) activates the procoagulant and proinflammatory contact system that drives both the kallikrein–kinin system and the intrinsic pathway of coagulation. When zymogen FXII ...comes into contact with negatively charged surfaces, it auto‐activates to the serine proteaseactivated FXII (FXIIa). Recently, various in vivo activators of FXII have been identified including heparin, misfolded protein aggregates, polyphosphate and nucleic acids. Murine models have established a central role of FXII in arterial and venous thrombosis. Despite its central function in thrombosis, deficiency in FXII does not impair haemostasis in animals and humans. In a preclinical cardiopulmonary bypass system in large animals, the FXIIa‐blocking antibody 3F7 prevented thrombosis; however, in contrast to traditional anticoagulants, bleeding was not increased. In addition to its function in thrombosis, FXIIa initiates formation of the inflammatory mediator bradykinin. This mediator increases vascular leak, causes vasodilation, and induces chemotaxis with implications for septic, anaphylactic and allergic disease states. Therefore, targeting FXIIa appears to be a promising strategy for thromboprotection without associated bleeding risks but with anti‐inflammatory properties.
Background
Robotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare ...robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices.
Methods
In a randomized crossover study, medical students (
n
= 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment.
Results
Surgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4;
p
= 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6;
p
= 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5;
p
= 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%),
p
= 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min;
p
= 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC.
Conclusions
Novices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model.
Registration number
researchregistry6029
Graphic abstract
Aims
In minimally invasive surgery (MIS), intraoperative guidance has been limited to verbal communication without direct visual guidance. Communication issues and mistaken instructions in training ...procedures can hinder correct identification of anatomical structures on the MIS screen. The iSurgeon system was developed to provide visual guidance in the operating room by telestration with augmented reality (AR).
Methods
Laparoscopic novices (
n
= 60) were randomized in two groups in a cross-over design: group 1 trained only with verbal guidance first and then with additional telestration with AR on the operative screen and vice versa for group 2. Training consisted of laparoscopic basic training and subsequently a specifically designed training course, including a porcine laparoscopic cholecystectomy (LC). Outcome included time needed for training, performance with Global Operative Assessment of Laparoscopic Skills (GOALS), and Objective Structured Assessment of Technical Skills (OSATS) score for LC, complications, and subjective workload (NASA-TLX questionnaire).
Results
Telestration with AR led to significantly faster total training time (1163 ± 275 vs. 1658 ± 375 s,
p
< 0.001) and reduced error rates. LC on a porcine liver was performed significantly better (GOALS 21 ± 5 vs. 18 ± 4,
p
< 0.007 and OSATS 67 ± 11 vs. 61 ± 8,
p
< 0.015) and with less complications (13.3% vs. 40%,
p
< 0.020) with AR. Subjective workload and stress were significantly reduced during training with AR (33.6 ± 12.0 vs. 30.6 ± 12.9,
p
< 0.022).
Conclusion
Telestration with AR improves training success and safety in MIS. The next step will be the clinical application of telestration with AR and the development of a mobile version for remote guidance.
Aims
Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two ...minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial.
Methods
In the ROLAF trial 40 patients with GERD were randomized to RALF (
n
= 20) or CLF (
n
= 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score.
Results
The GSRS score was similar for RALF (
n
= 15) and CLF (
n
= 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3,
p
= 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5,
p
= 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF 46% (6/13) vs. 33% (4/12),
p
= 0.806.
Conclusion
In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. Registration number: DRKS00014690 (
https://www.drks.de
).
Background
The aim of this study was to assess the transferability of surgical skills for the laparoscopic hernia module between the serious game Touch Surgery™ (TS) and the virtual reality (VR) ...trainer Lap Mentor™. Furthermore, this study aimed to collect validity evidence and to discuss “sources of validity evidence” for the findings using the laparoscopic inguinal hernia module on TS.
Methods
In a randomized crossover study, medical students (
n
= 40) in their clinical years performed laparoscopic inguinal hernia modules on TS and the VR trainer. TS group started with “Laparoscop
i
c Inguinal Hernia Module” on TS (phase 1: Preparation, phase 2: Port Placement and Hernia Repair), performed the module first in training, then in test mode until proficiency was reached. VR group started with “Inguinal Hernia Module” on the VR trainer (task 1: Anatomy Identification, task 2: Incision and Dissection) and also performed the module until proficiency. Once proficiency reached in the first modality, the groups performed the other training modality until reaching proficiency. Primary endpoint was the number of attempts needed to achieve proficiency for each group for each task/phase.
Results
Students starting with TS needed significantly less attempts to reach proficiency for task 1 on the VR trainer than students who started with the VR trainer (TS = 2.7 ± 0.6 vs. VR = 3.2 ± 0.7;
p
= 0.028). No significant differences for task 2 were observed between groups (TS = 2.3 ± 1.1 vs. VR = 2.1 ± 0.8;
p
= 0.524). For both phases on TS, no significant skill transfer from the VR trainer to TS was observed. Aspects of validity evidence for the module on TS were collected.
Conclusion
The results show that TS brought additional benefit to improve performances on the VR trainer for task 1 but not for task 2. Skill transfer from the VR trainer to TS could not be shown. VR and TS should thus be used in combination with TS first in multimodal training to ensure optimal training conditions.
Background
Multiple training modalities for laparoscopy have different advantages, but little research has been conducted on the benefit of a training program that includes multiple different ...training methods compared to one method only. This study aimed to evaluate benefits of a combined multi-modality training program for surgical residents.
Methods
Laparoscopic cholecystectomy (LC) was performed on a porcine liver as the pre-test. Randomization was stratified for experience to the multi-modality Training group (12 h of training on Virtual Reality (VR) and box trainer) or Control group (no training). The post-test consisted of a VR LC and porcine LC. Performance was rated with the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded experts.
Results
Training (
n
= 33) and Control (
n
= 31) were similar in the pre-test (GOALS: 13.7 ± 3.4 vs. 14.7 ± 2.6;
p
= 0.198; operation time 57.0 ± 18.1 vs. 63.4 ± 17.5 min;
p
= 0.191). In the post-test porcine LC, Training had improved GOALS scores (+ 2.84 ± 2.85 points,
p
< 0.001), while Control did not (+ 0.55 ± 2.34 points,
p
= 0.154). Operation time in the post-test was shorter for Training vs. Control (40.0 ± 17.0 vs. 55.0 ± 22.2 min;
p
= 0.012). Junior residents improved GOALS scores to the level of senior residents (pre-test: 13.7 ± 2.7 vs. 18.3 ± 2.9;
p
= 0.010; post-test: 15.5 ± 3.4 vs. 18.8 ± 3.8;
p
= 0.120) but senior residents remained faster (50.1 ± 20.6 vs. 25.0 ± 1.9 min;
p
< 0.001). No differences were found between groups on the post-test VR trainer.
Conclusions
Structured multi-modality training is beneficial for novices to improve basics and overcome the initial learning curve in laparoscopy as well as to decrease operation time for LCs in different stages of experience. Future studies should evaluate multi-modality training in comparison with single modalities.
Trial registration: German Clinical Trials Register DRKS00011040
Purpose
To systematically analyze the impact of prophylactic abdominal or retroperitoneal drain placement or omission in uro-oncologic surgery.
Methods
This systematic review follows the Cochrane ...recommendations and was conducted in line with the PRISMA and the AMSTAR-II criteria. A comprehensive database search including Medline, Web-of-Science, and CENTRAL was performed based on the PICO criteria. All review steps were done by two independent reviewers. Risk of bias was assessed with the Cochrane tool for randomized trials and the Newcastle–Ottawa Scale.
Results
The search identified 3427 studies of which eleven were eligible for qualitative and ten for quantitative analysis reporting on 3664 patients. Six studies addressed radical prostatectomy (RP), four studies partial nephrectomy (PN) and one study radical cystectomy. For RP a reduction in postoperative complications was found without drainage (odds ratio (OR)95% confidence interval (CI): 0.620.44;0.87,
p
= 0.006), while there were no differences for re-intervention (ORCI: 0.720.39;1.33,
p
= 0.300), lymphocele ORCI: 0.600.22;1.60,
p
= 0.310), hematoma (ORCI: 0.680.18;2.53,
p
= 0.570) or urinary retention (ORCI: 0.570.26;1.29,
p
= 0.180). For partial nephrectomy no differences were found for overall complications (ORCI: 0.990.65;1.51,
p
= 0.960) or re-intervention (ORCI: 1.160.31;4.38,
p
= 0.820). For RC, there were no differences for all parameters. The overall-quality of evidence was assessed as low.
Conclusion
The omission of drains can be recommended for standardized RP and PN cases. However, deviations from the standard can still mandate the placement of a drain and remains surgeon preference. For RC, there is little evidence to recommend the omission of drains and future research should focus on this issue.
Review Registration Number (PROSPERO)
CRD42019122885
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