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.
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.
Background
The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well ...shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.
Methods
A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.
Results
A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30–500 (RYGB) and 30–200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.
Conclusions
Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30–70, 70–150, and up to 500 RYGB, and after 30–50, 60–100, and 100–200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.
Purpose
To evaluate the impact of surgical caseload on safety, efficacy, and functional outcomes of laser enucleation of the prostate (LEP) applying a structured mentoring program.
Methods
Patient ...characteristics, perioperative data, and functional outcomes were analyzed descriptively. Linear and logistic regression models analyzed the effect of caseload on complications, functional outcomes and operative speed. Within the structured mentoring program a senior surgeon was present for the first 24 procedures completely, for partial steps in procedures 25–49, and as needed thereafter.
Results
A total of 677 patients from our prospective institutional database (2017–2022) were included for analysis. Of these, 84 (12%), 75 (11%), 82 (12%), 106 (16%), and 330 patients (49%) were operated by surgeons at (A) < 25, (B) 25–49, (C) 50–99, (D) 100–199, and (E) ≥ 200 procedures. Preoperative characteristics were balanced (all
p >
0.05) except for prostate volume, which increased with caseload.
There was no significant difference in change of IPSS, Quality of life, ICIQ, pad usage, peak urine flow, residual urine, and major complications (Group A: 8.3 to E: 7.6%,
p =
0.2) depending on the caseload. Caseload was not associated (Odds ratio: 0.7–1.4,
p >
0.2) with major complications in the multivariable logistic regression model. Only operating time was significantly shorter with increasing caseload in the multivariable analysis (111–55 min, beta 23.9–62.9,
p <
0.001).
Conclusion
With a structured mentoring program, the safety and efficacy of LEP can be ensured even during the learning curve with very good outcome quality. Only the operating time decreases significantly with increasing experience of the surgeon.
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.
A simulation of the thermonuclear explosion of a Chandrasekhar-mass C+O white dwarf, the most popular scenario of a Type Ia supernova (SN Ia), is presented. The underlying modeling is pursued in a ...self-consistent way, treating the combustion wave as a turbulent deflagration using well tested methods developed for laboratory combustion and based on the concept of "large-eddy simulations" (LESs). Such consistency requires to capture the onset of the turbulent cascade on resolved scales. This is achieved by computing the dynamical evolution on a 1024 super(3) moving grid, which resulted in the best-resolved three-dimensional SN Ia simulation carried out thus far, reaching the limits of what can be done on present supercomputers. Consequently, the model has no free parameters other than the initial conditions at the onset of the explosion, and therefore it has considerable predictive power. Our main objective is to determine to which extent such a simulation can account for the observations of normal SNe Ia. Guided by previous simulations with less resolution and a less sophisticated flame model, initial conditions were chosen that yield a reasonably strong explosion and a sufficient amount of radioactive nickel for a bright display. We show that observables are indeed matched to a reasonable degree. In particular, good agreement is found with the light curves of normal SNe Ia. Moreover, the model reproduces the general features of the abundance stratification as inferred from the analysis of spectra. This indicates that it captures the main features of the explosion mechanism of SNe Ia. However, we also show that even a seemingly best-choice pure deflagration model has shortcomings that indicate the need for a different mode of nuclear burning at late times, perhaps the transition to a detonation at low density.
Our closest living relatives, chimpanzees and bonobos, have a complex demographic history. We analyzed the high-coverage whole genomes of 75 wild-born chimpanzees and bonobos from 10 countries in ...Africa. We found that chimpanzee population substructure makes genetic information a good predictor of geographic origin at country and regional scales. Multiple lines of evidence suggest that gene flow occurred from bonobos into the ancestors of central and eastern chimpanzees between 200,000 and 550,000 years ago, probably with subsequent spread into Nigeria-Cameroon chimpanzees. Together with another, possibly more recent contact (after 200,000 years ago), bonobos contributed less than 1% to the central chimpanzee genomes. Admixture thus appears to have been widespread during hominid evolution.
Recurrent exacerbations are a major cause of morbidity and medical expenditure in patients with asthma. Various exogenous and endogenous factors are thought to influence the level of asthma control, ...but systematical data on the involvement of these factors in the recurrence of asthma exacerbations are scarce. In this study, 13 clinical and environmental factors potentially associated with recurrent exacerbations were investigated in 136 patients with difficult-to-treat asthma. Patients with more than three severe exacerbations (n = 39) in the previous year were compared with those with only one exacerbation per year (n = 24). A systematic diagnostic protocol was used to assess 13 potential risk factors. Factors significantly associated with frequent exacerbations included: severe nasal sinus disease (adjusted odds ratio (OR) 3.7); gastro-oesophageal reflux (OR 4.9); recurrent respiratory infections (OR 6.9); psychological dysfunctioning (OR 10.8); and obstructive sleep apnoea (OR 3.4). Severe chronic sinus disease and psychological dysfunctioning were the only independently associated factors (adjusted OR 5.5 and 11.7, respectively). All patients with frequent exacerbations exhibited at least one of these five factors, whilst 52% showed three or more factors. In conclusion, the results show that recurrent exacerbations in asthma are associated with specific co-morbid factors that are easy to detect and that are treatable. Therapeutic interventions aimed at correcting these factors are likely to reduce morbidity and medical expenditure in these patients.
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