Learning of Intracorporal Knot Tying in Minimally Invasive Surgery by Video or Expert Instruction.

INTRODUCTION: Minimally invasive surgery skill laboratories are indispensable in training, especially for complex procedural skills such as intracorporal suturing and knot tying (ICKT). However, maintaining a laboratory is expensive, and specially trained teachers are in short supply. During the COVID-19 pandemic, in-person instruction has reduced to almost zero, while model learning via video instruction (VID) has become an integral part of medical education. The aim of this study was to compare the learning effectiveness and efficiency of ICKT by laparoscopically inexperienced medical students through video versus direct expert instruction. MATERIALS AND METHODS: A secondary analysis of two randomized controlled trials was performed. We drew data from students who were trained in ICKT with expert instruction (EXP, n = 30) and from students who were trained via VID, n = 30). A laparoscopic box trainer including laparoscope was used for ICKT. Objective Structured Assessment of Technical Skills (OSATS), knot quality, and total ICKT time were the parameters for the assessment in this study. Proficiency criteria were also defined for these parameters. RESULTS: Students in the EXP group performed significantly better in OSATS-procedure-specific checklist (PSC) and knot quality compared with students in the VID group, with no difference in task time. Of the students who reached the proficiency criteria for OSATS-PSC and knot quality, those in the EXP group required fewer attempts to do so than those in the VID group. Students in both groups improved significantly in all parameters over the first hour of evaluation. CONCLUSION: For the laparoscopically inexperienced, training in ICKT through expert instruction presents an advantage compared with video-based self-study in the form of faster understanding of the procedure and the associated consistent implementation of good knot quality. Both teaching methods significantly improved participants' ICKT skills.

Incisional Hernia Rates After Laparoscopic or Open Abdominal Surgery-A Systematic Review and Meta-Analysis.

BACKGROUND: Incisional hernias are one of the most common long-term complications associated with open abdominal surgery. The aim of this review and meta-analysis was to systematically assess laparoscopic versus open abdominal surgery as a general surgical strategy in all available indications in terms of incisional hernia occurrence. METHODS: A systematic literature search was performed to identify randomized controlled trials comparing incisional hernia rates after laparoscopic versus open abdominal surgery in all indications. Random effects meta-analyses were calculated and presented as risk differences (RD) with their corresponding 95 % confidence intervals (CI). RESULTS: 24 trials (3490 patients) were included. Incisional hernias were significantly reduced in the laparoscopic group (RD -0.06, 95 % CI [-0.09, -0.03], p = 0.0002, I (2) = 75). The advantage of the laparoscopic procedure persisted in the subgroup of total-laparoscopic interventions (RD -0.14, 95 % CI [-0.22, -0.06], p = 0.001, I (2) = 87 %), whereas laparoscopically assisted procedures did not show a significant reduction of incisional hernias compared to open surgery (RD -0.01, 95 % CI [-0.03, 0.01], p = 0.31, I (2) = 35 %). Wound infections were significantly reduced in the laparoscopic group (RD -0.06, 95 % CI [-0.09, -0.03], p < 0.0001, I (2) = 35 %); overall postoperative morbidity was comparable in both groups (RD -0.06, 95 % CI [-0.13, 0.00], p = 0.06; I (2) = 64 %). Open abdominal surgery showed a significantly longer hospital stay compared to laparoscopy (RD -1.92, 95 % CI [-2.67, -1.17], p < 0.00001, I (2) = 87 %). At short-term follow-up, quality of life was in favor of laparoscopy. CONCLUSIONS: Incisional hernias are less frequent using the total-laparoscopic approach instead of open abdominal surgery. Whenever possible, the less traumatic access should be chosen.

A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it's time to randomize.

BACKGROUND: Laparoscopic distal pancreatectomy is regarded as a feasible and safe surgical alternative to open distal pancreatectomy for lesions of the pancreatic tail and body. The aim of the present systematic review was to provide recommendations for clinical practice and research on the basis of surgical morbidity, such as pancreas fistula, delayed gastric empting, safety, and clinical significance of laparoscopic versus open distal pancreatectomy for malignant and nonmalignant diseases of the pancreas. METHODS: A systematic literature search (MEDLINE) was performed to identify all types of studies comparing laparoscopic distal pancreatectomy and open distal pancreatectomy. Random effects meta-analyses were calculated after critical appraisal of the included studies and presented as odds ratios or mean differences each with corresponding 95% confidence intervals. RESULTS: A total of 4,148 citations were retrieved initially; available data of 29 observational studies (3,701 patients overall) were included in the meta-analyses. Five systematic reviews on the same topic were found and critically appraised. Meta-analyses showed superiority of laparoscopic distal pancreatectomy in terms of blood loss, time to first oral intake, and hospital stay. All other parameters of operative morbidity and safety showed no difference. Data on oncologic radicality and effectiveness are limited. CONCLUSION: Laparoscopic distal pancreatectomy seems to be a safe and effective alternative to open distal pancreatectomy. No more nonrandomized trials are needed within this context. A large, randomized trial is warranted and should focus on oncologic effectiveness, defined end points, and cost-effectiveness.