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.
Purpose
Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures.
...Materials and methods
A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation.
Results
The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (
n
= 12, 46%), metoclopramide (
n
= 11, 44%), and alvimopan (
n
= 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay mean difference (MD)
−
3.46 d, 95% confidence interval (CI) − 4.94 to − 1.98,
p
< 0.01, complications Odds ratio (OR) = 0.76, 95% CI 0.61–0.94,
p
= 0.01 and time to defecation (MD − 1.37 d, 95% CI − 2.06 to − 0.69,
p
< 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52–1.03,
p
= 0.07).
Conclusion
Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.
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.
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
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
Data from interventional studies suggest that a peritoneal flap after pelvic lymph node dissection (LND) during laparoscopic, robotic-assisted radical prostatectomy (RARP) may reduce the rate of ...symptomatic lymphoceles in transperitoneal approach. However, most of these studies are not conducted in a randomized controlled fashion, thus limiting their scientific value. A recent prospective, randomized, controlled trial (RCT) did not show superiority of a peritoneal flap while further trials are lacking. Therefore, the aim of the presented RCT will be to show that creating a peritoneal flap decreases the rate of symptomatic lymphoceles compared to the current standard procedure without creation of a flap.
PELYCAN is a parallel-group, patient- and assessor-blinded, phase III, adaptive randomized controlled superiority trial. Men with histologically confirmed prostate cancer who undergo transperitoneal RARP with pelvic LND will be randomly assigned in a 1:1 ratio to two groups-either with creating a peritoneal flap (PELYCAN) or without creating a peritoneal flap (control). Sample size calculation yielded a sample size of 300 with a planned interim analysis after 120 patients, which will be performed by an independent statistician. This provides a possibility for early stopping or sample size recalculation. Patients will be stratified for contributing factors for the development of postoperative lymphoceles. The primary outcome measure will be the rate of symptomatic lymphoceles in both groups within 6 months postoperatively. Patients and assessors will be blinded for the intervention until the end of the follow-up period of 6 months. The surgeon will be informed about the randomization result after performance of vesicourethral anastomosis. Secondary outcome measures include asymptomatic lymphoceles at the time of discharge and within 6 months of follow-up, postoperative complications, mortality, re-admission rate, and quality of life assessed by the EORTC QLQ-C30 questionnaire.
The PELYCAN study is designed to assess whether the application of a peritoneal flap during RARP reduces the rate of symptomatic lymphoceles, as compared with the standard operation technique. In case of superiority of the intervention, this peritoneal flap may be suggested as a new standard of care.
German Clinical Trials Register DRKS00016794 . Registered on 14 May 2019.
Comorbidities and frailty are determinants of surgical outcome. The aim of the study was to examine various measures of frailty and comorbidities in predicting postoperative outcome of partial ...nephrectomy (PN).
We prospectively analyzed the frailty and comorbidity status of 150 patients undergoing PN between 2015 and 2018. Primary endpoint was the occurrence of major postoperative complications (MPC) and secondary endpoints were the failure of Trifecta achievement and the need for hospital readmissions. For the transfer into clinical practice the most significant frailty parameters were summarized in a multi-dimensional test.
Median age was 67 (33–93) years, 64.7% of the patients were male. Univariable regression analysis showed, that patients with increased frailty indices (Hopkins frailty score ≥2 (OR = 3.74, p = 0.005), Groningen frailty index ≥4 (OR = 2.85, p = 0.036)) are at higher risk to develop MPC. Furthermore, poor physical performance, such as a low handgrip strength or a Full-Tandem-Stand (FTS) < 10 s were associated with MPC (OR = 4.76, p = 0.014; OR = 4.48, p = 0.018) and Trifecta failure (OR = 3.60, p = 0.037, OR = 5.50, p = 0.010).
Six measures were combined to the geriatric assessment in partial nephrectomy score (GAPN). A GAPN-score ≥3 proved to be a significant predictor for MPC (OR = 4.30, p = 0.029) and for Trifecta failure (OR = 0.20, p = 0.011) in multivariable regression analysis.
The frailty status and comorbidities are important determinants of the postoperative course after PN. These parameters should be assessed preoperatively and included in the treatment planning, especially in light of available alternative therapies. In this context, the GAPN-score may be a suitable tool.
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