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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.

AI is becoming ubiquitous, revolutionizing many aspects of our lives. In surgery, it is still a promise. AI has the potential to improve surgeon performance and impact patient care, from post-operative debrief to real-time decision support. But, how much data is needed by an AI-based system to learn surgical context with high fidelity? To answer this question, we leveraged a large-scale, diverse, cholecystectomy video dataset. We assessed surgical workflow recognition and report a deep learning system, that not only detects surgical phases, but does so with high accuracy and is able to generalize to new settings and unseen medical centers. Our findings provide a solid foundation for translating AI applications from research to practice, ushering in a new era of surgical intelligence.

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.

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.

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.

BackgroundLaparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. MethodsThis project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. ResultsTwenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563–648] vs 323 [130–464], p value 0.00036) and GOALS scores (14 [13–16] vs 10 [8–12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959–1010] vs 785 [626–856], p value 0.00009) and GOALS scores (16 [12–17] vs 12.5 [8.25–15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24–26] vs 17 [14–20], p value 0.0016 and CS 30 [27–32] vs 22[17.2–25.8], p value 0.00061).ConclusionIn conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Introduction FLS is an educational program developed by the Society of American Gastrointestinal and Endoscopic Surgeons and endorsed by the American College of Surgeons. The goal of the FLS program is to teach and assess the basic cognitive and psychomotor skills required to perform laparoscopic surgery. The purpose of this study is to review the results from the first 5 years of FLS certification testing. Methods FLS test data were prospectively collected for all participants taking the FLS certification examination since its inception. Deidentified data were reviewed and analyzed using standard descriptive statistics. Results The FLS examination was taken by 2,689 participants between October 2004 and December 2009. There was a yearly increase in the number of individuals seeking FLS certification. Complete demographic information was available for 1,882 participants: 12% were junior residents (PGY 1–3), 69% were senior residents (PGY 4–5) or fellows, and 19% were attending surgeons. A breakdown of participants by specialty revealed that 88% were general surgeons, 4% were gynecologists, 2% were urologists, and 6% were labeled as “other.” The mean (standard deviation, SD) score on the cognitive examination was 519 (157), with a 93% pass rate. The mean score on the technical skills examination was 525 (117), with a 92% pass rate. After combining both scores, the overall FLS certification pass rate was 88%. Conclusions The FLS certification examination has gained widespread acceptance among laparoscopic surgeons in training and practice, with a marked increase in testing since the American Board of Surgery mandate for certification was announced. The overall pass rate of 88% on the examination approaches the target pass rate of 90% established during the test-setting process.

Background The fundamentals of laparoscopic surgery (FLS) program has been extensively validated for use as a high-stakes examination for certification purposes, but optimal methods for its use in skills training have not been described. This study aimed to investigate the feasibility of implementing a proficiency-based FLS skills training curriculum and to evaluate its effectiveness in preparing trainees for certification. Methods For this study, 21 novice medical students at two institutions viewed video tutorials, then performed one repetition of the five FLS tasks as a pretest. The pretests were scored using standard testing metrics. The trainees next practiced the tasks over a 2-month period until they achieved proficiency for all the tasks. A modified on-the-fly scoring system based on expert-derived performance was used. The trainees were posttested using the high-stakes examination format. Results No trainee passed the certification examination at pretesting. The trainees achieved proficiency for 96% of the five tasks during training, which required 9.7 ± 2.4 h (range, 6–14 h) and 119 ± 31 repetitions (range, 66–161 repetitions). The trainees rated the proficiency levels as “moderately difficult” (3.0 ± 0.7 on a 5-point scale) and “highly appropriate” (4.7 ± 0.1 on a 5-point scale). At posttesting, 100% of the trainees passed the certification examination and demonstrated significant improvement compared with pretesting for normalized score (468 ± 24 vs 126 ± 75; p  < 0.001), self-rated laparoscopic comfort (89.4% vs 4.8%; p  < 0.001), and skill level (3.6 ± 0.9 vs 1.2 ± 0.5; p  < 0.001, 5-point scale). Conclusions This proficiency-based curriculum is feasible for training novices and uniformly allows sufficient skill acquisition for FLS certification. Endorsed by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), this curriculum is available for use as an optimal method for FLS skills training. More widespread adoption of this curriculum is encouraged.

Background The incidence of incisional hernia has not decreased despite the use of laparoscopy for colon resections. The objective of this study is to evaluate the impact of the incision used for specimen extraction on the incidence of incisional hernia after laparoscopic colectomy. Methods Patients who underwent laparoscopic colectomy without stoma at a single university tertiary-care centre from 2003 to 2009 were identified from an operating room database. Patients were contacted by telephone for participation, and underwent physical examination ± ultrasonography for incisional hernia at the specimen extraction site and completed the Body Image Questionnaire. Specimen extraction incisions were classified into midline, transverse and Pfannenstiel groups. Results Out of a total of 251 patients, 99 patients agreed to participate (68 midline, 7 transverse, 24 Pfannenstiel), while 73 patients refused consent and 79 patients could not be contacted. Patients who refused consent were older (69.8 vs 62.4 years, p  = 0.001) but otherwise were similar to participants with respect to gender, malignant disease, postoperative complications and extraction site. Mean length of follow-up was 37.0 months. The overall incidence of incisional hernia was 21% (21/99), being 29 % (20/68) after midline incision compared with 14 % (1/7) after transverse and 0 % (0/24) after Pfannenstiel incisions ( p  = 0.002). Of patients with incisional hernia, 47 % (10/21) were symptomatic. Patients with incisional hernia had lower cosmetic score (14.4 vs 17.7, p  = 0.02) compared with those without, but there was no difference in body image score. There were no differences in body image or cosmesis between the three incisions. Conclusions There is a high incidence of symptomatic incisional hernia after midline specimen extraction in laparoscopic colectomy, which negatively impacts cosmesis. The risk of hernia may be lower with the use of a transverse or Pfannenstiel incision for specimen extraction.

The precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function. A literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings--renal blood flow, pneumoperitoneum, renal function, and laparoscopy--were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles. The literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum. There appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.