Development and implementation of an assessment tool to evaluate technical skills in the insertion of implantable venous access devices, a Prospective Cohort Study.

OBJECTIVE: Based on the Competency Assessment Tool, herein we developed an assessment instrument suitable to evaluate the implantation of central intravenous devices. BACKGROUND: Surgical assessment is based mainly on the subjective impressions of the teacher. Based on the "Competency Assessment Tool" (CAT) developed for the evaluation of technical surgical skills in minimally invasive colorectal resection, we designed an assessment tool suitable to evaluate the implantation of central venous access devices performed by junior surgical trainees. METHODS: Four major assessments during the different steps of the intervention were used in this evaluation. Each of these tasks was divided into four sub-domains according to surgical skill. In addition to the CAT score, the apprentices' skills were evaluated using a visual assessment that was quantified using an analogue scale (value from 1 to 10). The candidates were classified into junior and senior trainees depending on the number of procedures they had already performed and on their surgical experience. RESULTS: 71 procedures were evaluated during the study period. Seven senior trainees conducted 43 procedures and five junior trainees performed 28 interventions. The senior trainees had significantly higher CAT scores than junior candidates, and the scores fluctuated according to surgical experience, usually reaching their peak after 10 procedures. CONCLUSIONS: The CAT model is well suited for the assessment of surgical trainees during central venous access device implantation. It enables a close assessment of the learning process and the technical skills of trainees, which helps them improving in a safe, standardized manner.

Ileal pouch-anal anastomosis with fluorescence angiography: a case-matched study.

AIM: An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tension-free ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement. METHODS: Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique. RESULTS: Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60). CONCLUSION: FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.

Iatrogenic ureteral injuries and their prevention in colorectal surgery: results from a nationwide survey.

AIM: Iatrogenic ureteral injury (IUI) occurs rarely during colorectal surgery but is associated with significant mortality, morbidity and medicolegal issues. Few cases are reported, and recommendations regarding prevention are lacking. The aim of this study is to describe the current state of practice regarding IUI and its prevention among general surgeons in Switzerland. METHOD: All Swiss general surgeons who are members of either the Swiss Association of Laparoscopic and Thoracoscopic Surgery or the Swiss Surgical Society were invited to participate in an anonymous online survey. Demographics, surgical practice, rate of IUI and methods used to prevent IUI were investigated. RESULTS: All participants were board-certified general surgeons, 63.4% were certified visceral surgeons and 17.9% were certified colorectal surgeons. The mean level of experience in colorectal surgery was 15.6 ± 9.2 years. Formal ureter identification was considered mandatory during sigmoid or rectal surgery by 83.7% of participants, and 31.7% considered identification of the right ureter during right colectomy to be mandatory. In total, 61.8% of the participants and 78.4% of surgeons with more than 20 years of experience had encountered at least one IUI. Prophylactic ureteral stenting was considered useful in complex procedures by 93.5% of participants, and 56.9% had used stents at least once in the past 12 months. Noninvasive techniques for identifying ureters would be considered in regular daily practice by 54.5% of the participants. CONCLUSION: Most general surgeons experience IUI. Ureter identification is widely integrated in colorectal procedures. Prophylactic stenting is widely used for difficult cases. Noninvasive methods to improve ureter identification are now needed.

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery.

BACKGROUND: Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery. METHODS: This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone. RESULTS: Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology. CONCLUSION: Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Intra-Abdominal Cooling System Limits Ischemia-Reperfusion Injury During Robot-Assisted Renal Transplantation.

Robot-assisted kidney transplantation is feasible; however, concerns have been raised about possible increases in warm ischemia times. We describe a novel intra-abdominal cooling system to continuously cool the kidney during the procedure. Porcine kidneys were procured by standard open technique. Groups were as follows: Robotic renal transplantation with (n = 11) and without (n = 6) continuous intra-abdominal cooling and conventional open technique with intermittent 4°C saline cooling (n = 6). Renal cortex temperature, magnetic resonance imaging, and histology were analyzed. Robotic renal transplantation required a longer anastomosis time, either with or without the cooling system, compared to the open approach (70.4 ± 17.7 min and 74.0 ± 21.5 min vs. 48.7 ± 11.2 min, p-values < 0.05). The temperature was lower in the robotic group with cooling system compared to the open approach group (6.5 ± 3.1°C vs. 22.5 ± 6.5°C; p = 0.001) or compared to the robotic group without the cooling system (28.7 ± 3.3°C; p < 0.001). Magnetic resonance imaging parenchymal heterogeneities and histologic ischemia-reperfusion lesions were more severe in the robotic group without cooling than in the cooled (open and robotic) groups. Robot-assisted kidney transplantation prolongs the warm ischemia time of the donor kidney. We developed a novel intra-abdominal cooling system that suppresses the noncontrolled rewarming of donor kidneys during the transplant procedure and prevents ischemia-reperfusion injuries.

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome. METHODS: One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal). RESULTS: Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10-17), and median FISI was 20 (range 0-61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03). CONCLUSIONS: These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

Incisional hernia after robotic single-site cholecystectomy: a pilot study.

PURPOSE: Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci® Single-Site®) with the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique. METHODS: In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected. RESULTS: We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m2 [±SD 4.1 kg/m2]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients. CONCLUSION: This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience.

BACKGROUND: Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes. METHODS: A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression. RESULTS: Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up. DISCUSSION: Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.

Subtotal colectomy for ulcerative colitis: lessons learned from a tertiary centre.

AIM: Subtotal colectomy (STC) is a well-established treatment for complicated and refractory ulcerative colitis (UC). A laparoscopic approach offers potentially improved outcomes. The aim of the study was to report our experience with STC for UC in a single large centre. METHOD: From January 2007 to May 2015, all consecutive patients undergoing STC for UC were retrospectively analysed from a prospectively managed database. Patients with known Crohn's disease or those undergoing one-stage procedures were excluded. Demographics, perioperative outcomes and second-stage procedures were analysed. RESULTS: During the study period, 151 STCs were performed for UC [100 emergency (66%) and 51 elective (34%)]. Acute severe colitis refractory to therapy was the most common indication (62%). Overall, 117 laparoscopic (78%) and 34 open STCs were performed, with a conversion rate of 14.5%. Mortality and morbidity rates were 0.7% and 38%, respectively. Whilst operative time was shorter for open STC (by 75 min; P = 0.001), there were fewer complications (32% vs 62%; P = 0.002) and a shorter hospital stay (by 6.9 days; P = 0.0002) following laparoscopic STC. Fewer complications and shorter hospital stay were also observed after elective STC. Patients undergoing laparoscopic STC were more likely to undergo a restorative second-stage procedure than those having open STC (75% vs 50%; P = 0.03). CONCLUSION: Laparoscopic STC for UC is feasible and safe, even in the emergency situation. A laparoscopic approach may offer advantages in terms of lower morbidity and reduced length of stay. Elective resection may offer similar advantages and is best performed whenever possible.

Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer.

AIM: In advanced pelvic cancer it may be necessary to perform a total pelvic exenteration. In such cases urinary tract reconstruction is usually achieved with the creation of an ileal conduit with a urinary stoma on the right side of the patient's abdomen and an end colostomy separately on the left. The potential morbidity from a second stoma may be avoided by the use of a double-barrelled wet colostomy (DBWC), as a single stoma. Another advantage is the possibility of using a vertical rectus abdominis muscle flap for perineal reconstruction. METHOD: All patients undergoing formation of a DBWC were included. RESULT: A DBWC was formed in 10 patients. One patient underwent formation of a double-barrelled wet ileostomy. CONCLUSIONS: In this technical note we present our early experience in 11 cases and a video of DBWC formation in a male patient.