Explore the vast range of titles available.

Introduction The incidence of incisional hernia(IH) may be affected by the choice of specimen extraction incision. The objective of this study was to perform a systematic review and meta-analysis comparing the incidence of IH after midline and off-midline incisions in patients undergoing laparoscopic colorectal surgery. Methods A systematic search was performed according to PRISMA guidelines to identify all comparative studies from January 1991–August 2016 on the incidence of IH after midline and off-midline(transverse or Pfannenstiel) incisions in patients undergoing laparoscopic colorectal surgery. Case series and studies reporting the IH after stoma site extraction, SILS, or NOTES were excluded. The MINORS instrument was used for quality assessment for observational studies. Weighted estimates were calculated using a random-effects model. Results A total of 17 articles were identified and included for meta-analysis, 16 of which were observational studies and 1 was an RCT. The mean MINORS score for observational studies was 12.9 (SD 3.2, range 7–17). Sample sizes in the midline (mean 185, range 20–995) and off-midline(mean 184, range 20–903) groups were similar. Follow-up ranged from 17.3 to 42 months. The pooled incidence of IH was 10.6% (338/3177) in midline, 3.7% (48/1314) in transverse, and 0.9% (9/956) in Pfannenstiel incisions. IH was significantly higher in the midline compared to off-midline groups (weighted OR 4.1, 95% CI 2.0–8.3, I 2  = 79.7%, p for heterogeneity <0.001). Midline incisions were also at higher risk of IH versus transverse (weighted OR 3.0, 95% CI 1.4–6.7, I 2  = 72.7%, p for heterogeneity <0.001) and Pfannenstiel (weighted OR 8.6, 95% CI 3.0–24.6, I 2  = 43.5%, p for heterogeneity = 0.101) incisions. There was no publication bias according the funnel plot or statistically (Egger’s p  = 0.336). Conclusions Midline incisions for specimen extraction in laparoscopic colorectal surgery are at significantly higher risk of IH compared to off-midline (transverse or Pfannenstiel) incisions, but these data are of poor quality and heterogeneous.

Purpose The purpose of this narrative review is to provide a framework from which to measure the outcomes of Enhanced Recovery After Surgery (ERAS) programs. Principle findings We define the outcomes of recovery from the perspective of different stakeholders and time frames. There is no single definition of recovery. There are overlapping phases of recovery which are of particular interest to different stakeholders (surgeons, anesthesiologists, nurses, patients and their caregivers), and the primary outcome of interest may vary depending on the phase and the perspective. In the earliest phase (from the end of the surgery to discharge from the postanesthesia care unit [PACU]), biologic and physiologic outcomes are emphasized. In the intermediate phase (from PACU to discharge from the hospital), symptoms related to pain and gastrointestinal function as well as basic activities are important. Studies of ERAS pathways have reported clinical outcomes and symptoms, including complications, hospital stay, mobilization, and gastrointestinal function, largely during hospitalization. Nevertheless, patients define recovery as return to normal functioning, a process that occurs over weeks to months (late phase). Outcomes reflecting functional status (e.g., physical activity, activities of daily living) and overall health (e.g., quality of life) are important in this phase. To date, few studies reporting the effectiveness of ERAS pathways compared with conventional care have included functional status or quality-of-life outcomes, and there is little information about recovery after discharge from hospital. Conclusion Recovery after surgery is a complex construct. Different outcomes are important at different phases along the recovery trajectory. Measures for quantifying recovery in hospital and after discharge are available. A consensus-based core set of outcomes with input from multiple stakeholders would facilitate research reporting.

Background Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care. Methods Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test [6MWT]). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range [IQR]) and were analyzed using Chi-square and Student’s t test. All p values lower than 0.05 were considered significant. Results The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m; p  = 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m ( p  < 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m; p  = 0.01) and 8 weeks (mean difference, 84.5 ± 83 m; p  < 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group ( p  < 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery. Conclusion In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).

The epidural injection is a medical intervention to inject therapeutics directly into the vicinity of the spinal cord for pain management. Because of its proximity to the spinal cord, imprecise insertion of the needle may result in irreversible damage to the nerves or spinal cord. This study explores enhancing procedural accuracy by integrating a telerobotic system and augmented reality (AR) assistance. Tele-kinesthesia is achieved using a leader–follower integrated system, and stable force feedback is provided using a novel impedance-matching force rendering approach. In this domain, augmented reality employs a magnetic-tracker-based approach for real-time 3D model projection onto the patient’s body, aiming to augment the physician’s visual field and improve needle insertion accuracy. Preliminary results indicate that our AR-enhanced robotic system may reduce the cognitive load and improve the accuracy of ENI, highlighting the promise of AR technologies in complex medical procedures. However, further studies with larger sample sizes and more diverse clinical settings must comprehensively validate these findings. This work lays the groundwork for future research into integrating AR into medical robotics, potentially transforming clinical practices by enhancing procedural safety and efficiency.

The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the operating room (OR). Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores ≤15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. Sixteen residents completed the study. There were no differences in baseline simulator (49.1 ± 17 vs 39.5 ± 16, P = .27) or OR scores (11.3 ± 2.0 vs 12.0 ± 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 ± 4 vs 60.5 ± 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 ± 2.2 ( P = .04), whereas the trained group improved by 6.1 to 17.4 ± 1.9 ( P = .0005 vs control; P < .0001 vs baseline). This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.

Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.

Introduction Patients, clinicians and researchers seek an easy, reproducible and valid measure of postoperative recovery. The six-minute walk test (6MWT) is a low-cost measure of physical function, which is a relevant dimension of recovery. The aim of the present study was to contribute further evidence for the validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. Methods This study involved a sample of 174 patients enrolled in three previous randomized controlled trials. Construct validity was assessed by testing the hypotheses that the distance walked in 6 min (6MWD) at 4 weeks after surgery is greater (1) in younger versus older patients, (2) in patients with higher preoperative physical status versus lower, (3) after laparoscopic versus open surgery, (4) in patients without postoperative complications versus with postoperative complications; and that 6MWD (5) correlates cross-sectionally with self-reported physical activity as measured with a questionnaire (CHAMPS). Statistical analysis was performed using linear regression and Spearman’s correlation. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to guide the formulation of hypotheses and reporting of results. Results One hundred and fifty-one patients who completed the 6MWT at 4 weeks after surgery were included in the analysis. All hypotheses tested for construct validity were supported by the data. Older age, poorer physical status, open surgery and occurrence of postoperative complications were associated with clinically relevant reduction in 6MWD (>19 m). There was a moderate positive correlation between 6MWD and patient-reported physical activity ( r  = 0.46). Conclusions This study contributes further evidence for the construct validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. Results from this study support the use of the 6MWT as an outcome measure in studies evaluating interventions aimed to improve postoperative recovery.

Primary nonparasitic splenic cysts (NPSC) are typically diagnosed incidentally. The management of large (≥ 5 cm) asymptomatic cysts remains controversial; there is a lack of evidence guiding management. The purpose of this study was to describe the outcomes of nonoperative management of large NPSC. Patients diagnosed with NPSC between January 2004 and December 2019 were identified at our academic institution. Adult patients with an NPSC of at least 5 cm who had at least 1 additional hospital visit were included. Data are presented as medians with interquartile ranges (IQR). We identified 512 medical records that included the term splenic cyst during the study period. Sixty-eight of the patients had no reported cyst size, 410 had cysts smaller than 5 cm, 1 patient underwent an elective splenectomy at another institution and 12 patients were excluded for other reasons; 21 patients with cysts of at least 5 cm were included in the study. Eight symptomatic patients underwent surgery at our institution. Of these, 2 presented acutely: 1 with hemoperitoneum who required admission for transfusions and later underwent elective laparoscopic splenectomy and 1 with increasingly severe abdominal pain who underwent laparoscopic cyst unroofing. The remaining 6 symptomatic patients had elective surgery for pain (4 cyst unroofing, 1 total splenectomy, 1 partial splenectomy). Thirteen patients were asymptomatic (10 female, median age 49.2 [IQR 38.1 to 64.6] yr). Two of these patients chose to undergo elective surgery. The remaining 11 asymptomatic patients, with a median initial cyst size of 8.0 (IQR 5.3 to 10.8) cm, were followed for a median of 31.0 (IQR 23.5 to 71.0) months. There was no change in median cyst size (0 [IQR −1 to 0] cm), and none of these patients underwent intervention for their NPSC. Asymptomatic patients managed nonoperatively for large NPSC did not become symptomatic or require intervention during the study period. This supports watchful waiting with serial radiologic and clinical monitoring for asymptomatic large NPSC. Les kystes spléniques non parasitaires primaires (KSNPP) sont généralement découverts fortuitement. La prise en charge des kystes volumineux (≥ 5 cm) asymptomatiques ne fait pas l’unanimité; les données probantes manquent pour orienter le traitement. Cette étude avait pour but de décrire les résultats d’une prise en charge non chirurgicale des KSNPP. Nous avons identifié les patients ayant reçu un diagnostic de KSNPP entre janvier 2004 et décembre 2019 dans notre établissement universitaire. Nous avons inclus les patients adultes porteurs d’un KSNPP d’au moins 5 cm qui avaient consulté au moins 1 autre fois à l’hôpital. Les données sont présentées sous forme de médianes et d’écarts interquartiles (ÉI). Nous avons recensé 512 dossiers médicaux incluant le terme kyste splénique durant la période de l’étude. Chez 68 patients, la taille du kyste n’était pas indiquée; 410 avaient un kyste de moins de 5 cm; 1 patient a subi une splénectomie non urgente dans un autre établissement et 12 ont été exclus pour d’autres raisons; 21 patients porteurs d’un kyste d’au moins 5 cm ont été retenus pour l’étude. Huit patients symptomatiques ont subi une chirurgie dans notre établissement. Parmi eux, 2 étaient des cas urgents : 1 cas d’hémopéritoine pour lequel le patient a dû être hospitalisé pour des transfusions et a ensuite subi une splénectomie laparoscopique non urgente, et 1 cas d’intense douleur abdominale croissante pour lequel le patient a subi une fenestration laparoscopique. Les 6 autres patients symptomatiques ont subi une chirurgie non urgente pour la douleur (4 fenestrations, 1 splénectomie totale, 1 splénectomie partielle). Treize patients étaient asymptomatiques (10 femmes, âge médian 49,2 [écart interquartile (ÉI) de 38,1 à 64,6] ans). Deux d’entre eux ont opté pour la chirurgie non urgente. Les 11 patients asymptomatiques restants, dont la taille médiane des kystes initiaux était de 8,0 (EI de 5,3 à 10,8) cm, ont été suivis pendant une durée médiane de 31,0 (ÉI de 23,5 à 71,0) mois. On n’a noté aucun changement de la taille médiane des kystes (0 [ÉI de −1 à 0] cm) et aucun de ces patients n’a subi d’intervention pour son KSNPP. Les patients asymptomatiques traités non chirurgicalement pour un KSNPP volumineux ne sont pas devenus symptomatiques et n’ont pas été obligés d’être opérés pendant la période de l’étude. Cela milite en faveur de l’attente vigilante, avec suivi radiologique et clinique, pour les cas de KSNPP volumineux asymptomatiques.

Introduction Surgery is evolving, and new techniques are introduced to improve “recovery.” Postoperative recovery is complex, and evaluating the effectiveness of surgical innovations requires assessment of patient-reported outcomes. The Short-Form-36 (SF-36), a generic health-related quality of life questionnaire, is the most commonly used instrument in this context. The objective of this study was to contribute evidence for the validity of the SF-36 as a metric of postoperative recovery. Methods Data from 128 patients undergoing planned colorectal surgery at one university hospital between 2005 and 2010 were analyzed. In the absence of a gold standard, the responsiveness and construct validity (known groups and convergent) of the SF-36 were evaluated. Standardized response means were computed for the former and non-parametric tests were used to assess the statistical significance of the changes observed. Multiple linear regression was used to determine whether the SF-36 discriminates between patients with versus without complications and between laparoscopic and open surgery (known groups); correlations between the SF-36 and the 6-min walk test, a measure of functional walking capacity (convergent) was investigated with Spearman’s rank correlation. Results The SF-36 was sensitive to clinically important changes. Scores on six of eight domains and the physical component summary score deteriorated postoperatively (SRM 0.86 for the PCS, p  < 0.01) and improved to baseline thereafter. Patients with complications had significantly lower scores on five SF-36 domains (with differences from −9 (−18, −1), p  = 0.04 to −18 (−32, −2), p  = 0.03), and scores on all subscales were lower than those in a healthy population ( p  < 0.01 to p  = 0.04). The SF-36 did not differentiate between laparoscopic and open surgery. Physical functioning scores correlated with 6MWT distance at 1 and 2 months (Spearman’s r  = 0.31 and 0.36, p  < 0.01). Conclusions The SF-36 is responsive to expected physiological changes in the postoperative period, demonstrates construct validity, and thus constitutes a valid measure of postoperative recovery after planned colorectal surgery. The SF-36 did not, however, discriminate between recovery after laparoscopic and open surgery.

BackgroundTelesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR).MethodsIn this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2–3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points.ResultsSix residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training.ConclusionThe use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.