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Mental imagery (MI) aids skill acquisition, however, it is unclear to what extend MI is used by experienced surgeons. The purpose of this study was to assess differences in MI of participants with varying surgical expertise in robotic surgery. Students, residents, and surgeons completed the Mental Imagery Questionnaire to assess MI for robotic suturing. Participants then completed robotic simulator tasks, and imagined performing robotic suturing while being assessed with electroencephalogram (EEG). Attending surgeons reported higher MI for robotic suturing, and EEG revealed higher neural activation during imagery of robotic suturing than other groups. Experienced surgeons displayed higher MI ability for robotic suturing, and displayed higher cortical activity in the frontal and parietal areas of the brain, which is associated with more advanced motor imagery. MI appears to be a component of robotic surgery expertise. •We aimed to assess differences in MI ability among different surgical experience levels.•Experienced surgeons had higher EEG-assessed neural activity during imagery.•Experienced surgeons reported higher imagery of robotic suturing.•EEG is a viable objective assessment method of surgery-specific mental imagery.

BackgroundColorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. MethodsSystematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. ResultsThe panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. ConclusionsThese evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

Several studies demonstrated that simulator-acquired skill transfer to the operating room is incomplete. Our objective was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. Trainees completed baseline assessments including intracorporeal suturing (IS) performance, attentional selectivity, self-reported use of mental skills, and self-reported prior clinical and simulated laparoscopic experience and confidence. Residents then followed proficiency-based laparoscopic skills training, and their skill transfer was assessed on a live-anesthetized porcine model. Predictive characteristics for transfer test performance were assessed using multiple linear regression. Thirty-eight residents completed the study. Automaticity, attentional selectivity, resident perceived ability with laparoscopy and simulators, and post-training IS performance were predictive of IS performance during the transfer test. Promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. Mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal. •Automaticity and attentional selectivity predict the transfer of skill.•Perceived ability in laparoscopic surgery was predictive of skill transfer.•Perceived ability on laparoscopic simulators was predictive of skill transfer.•Focusing on these factors may facilitate more complete skill transfer for trainees.

Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures. Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis. 151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 ​min delay (p ​< ​0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined. The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time. [Display omitted] •We discovered the most common operating room inefficiencies in a wide range of procedures.•We also identified the most common procedure steps the inefficiencies take place in.•We identified the exact time delay inefficiencies cause and ways to prevent them.

BackgroundAchalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia.MethodsWe conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively.ResultsFrom 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment “success” RR 1.71, 95% CI 1.34–2.17; 126 patients) and in observational studies (Eckardt score MD − 0.43, 95% CI − 0.71 to − 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08–0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6–12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02–7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events.ConclusionsPOEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.

IntroductionImproving operating room (OR) inefficiencies benefits the OR team, hospital, and patients alike but the available literature is limited. Our goal was, using a novel surgical application, to identify any OR incidents that cause delays from the time the patient enters the OR till procedure start (preparatory phase).Materials and methodsWe conducted an IRB approved, prospective, observational study between July 2018 and January 2019. Using a novel surgical application (ExplORer Surgical) three observers recorded disrupting incidents and their duration during the preparatory phase of a variety of general surgery cases. Specifically, the number and duration of anesthesia delays, unnecessary/distracting conversations, missing items, and other delays were recorded from the moment they started until they stopped affecting the normal workflow.ResultsNinety-six OR cases were assessed. 20 incidents occurred in 18 (19%) of those cases. The average preparatory duration for all the cases was 20.7 ± 8.6 min. Cases without incidents lasted 19.5 ± 7.4 min while cases with incidents lasted 25.9 ± 11.2 min, p = 0.03. The average incident lasted 3.7 min, approximately 18% of the preparatory phase duration.ConclusionThe use of the ExplORer Surgical app allowed us to accurately record the incidents happening during the preparatory phase of various general surgery operations. Such incidents significantly prolonged the preparatory duration. The identification of those inefficiencies is the first step to targeted interventions that may eventually optimize the efficiency of preoperative preparation.

BackgroundPrimary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver’s two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies.MethodsA systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations.ResultsThe panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence).ConclusionGiven the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.Executive summaryBackgroundThe multidisciplinary management of both primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) may include liver-directed therapies as part of treatment algorithms; these algorithms focus heavily on control of liver-specific disease as in many cases this serves as a proxy for long-term survival. Hepatectomy is the primary treatment option in patients who can tolerate resection for both HCC and CRLM. Liver-directed therapies include arterial embolization, stereotactic body radiation therapy, and liver ablation. Over the last several decades, microwave ablation (MWA) and radiofrequency ablation (RFA) of liver tumors have been used in high-risk patients unfit for surgical intervention or tumors not amenable to local control with other therapies. As ablation is an evolving technology, outcomes data are primarily reported in liver tumors less than 3 cm in diameter, while data for liver tumors greater than 3 cm are limited for both HCC and CRLM. The authors sought to perform a systematic review of the existing data to assess for meaningful conclusions. Therefore, a multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others regarding the role of liver ablation in the treatment of HCC and CRLM up to 5 cm in diameter.MethodsA systematic review was conducted for six key questions (KQ) regarding the use of either MWA or RFA for solitary HCC or CRLM. Due to the paucity of evidence available, HCC and CRLM less than 5 cm in diameter were combined into two final KQs which were used to develop recommendations. Evidence-based recommendations were formulated using the GRADE methodology by subject matter experts. Additionally, the panel developed recommendations for future research.Interpretation of strong and conditional recommendationsAll guideline recommendations were assigned “conditional” recommendations. These were based on the GRADE approach. The words “the guideline panel suggests” were used for conditional recommendations.Key questions addressed by these guidelinesShould MWA (laparoscopic or open) vs. RFA (laparoscopic or open) be used for HCC or CRLM less than 5 cm ineligible for other therapies?Should laparoscopic MWA vs. percutaneous MWA be used for HCC and/or CRLM less than 5 cm ineligible for other therapies?RecommendationsShould MWA (laparoscopic or open) vs. RFA (laparoscopic or open) be used for HCC or CRLM less than 5 cm ineligible for other therapies?The panel suggests MWA and RFA are both safe and feasible. There was insufficient evidence to recommend one modality over another in terms of oncologic outcomes (conditional recommendation, very low certainty of evidence).Should laparoscopic MWA vs. percutaneous MWA be used for HCC and/or CRLM less than 5 cm ineligible for other therapies?The panel suggests that either ablative approach achieves similar overall outcomes, albeit through distinct patterns. The laparoscopic approach obtained better local control and the percutaneous approach had fewer morbidities while obtaining similar overall 1-year survival (conditional recommendation, very low certainty of evidence).How to use these guidelinesThe aim of these guidelines is to assist surgeons and physicians in making management decisions for patients with HCC or CRLM. Given that the evidence for this guideline was based on very low certainty evidence, these guidelines should be applied with caution. They are also intended to provide education, inform advocacy, and describe future areas for research. The guidelines are not meant to mandate a particular approach or strategy given the lack of evidence and intricacies of the healthcare environment, individual patient needs, comorbidities, and surgeon experience. Specific situations require adjustment of treatment plans to suit the needs and priorities of the individual patient. Finally, since the guidelines take a patient-centered approach, patients can use these guidelines as a source of information and for discussion with their physicians.

BackgroundPrimary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm.MethodsA systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data.ResultsFrom 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm.ConclusionThe available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.

BackgroundWhile surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor.MethodsPubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000—September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle–Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD).ResultsFrom 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70–1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84–1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38–1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17).ConclusionsCurrent evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

Interventions to manage disease in wild animals are challenging, being characterised by sparse information on the distribution of infection and a limited ability to target infected individuals. In parts of Europe, the persistence of bovine tuberculosis (bTB caused by Mycobacterium bovis) in cattle is linked to reservoirs of infection in wild populations of European badgers (Meles meles). In this study, we describe the development of a method for the safe restraint and blood sampling of badgers in the field without recourse to anaesthesia. The approach utilises a specially designed cage to physically restrain badgers and a protocol for obtaining a blood sample from the metatarsal pad. In field trials, blood samples were successfully obtained on 30 of 33 occasions, and all samples produced a valid trap-side result using a rapid serological test. Same day examination of restrained animals detected no injuries other than the blood sampling incision site, and there was no evidence of a negative effect of restraint on subsequent recapture probability. The approach negates the need for field anaesthesia to obtain a diagnostic sample, thus eliminating the risks of associated adverse effects, reducing costs and time before release back into the wild. These advantages could expand current options for surveillance and disease control interventions in badgers by permitting more efficient trap-side sampling and testing.