Conception and prospective multicentric validation of a Robotic Surgery Training Curriculum (RoSTraC) for surgical residents: from simulation via laboratory training to integration into the operation room.

There is a lack of training curricula and educational concepts for robotic-assisted surgery (RAS). It remains unclear how surgical residents can be trained in this new technology and how robotics can be integrated into surgical residency training. The conception of a training curriculum for RAS addressing surgical residents resulted in a three-step training curriculum including multimodal learning contents: basics and simulation training of RAS (step 1), laboratory training on the institutional robotic system (step 2) and structured on-patient training in the operating room (step 3). For all three steps, learning content and video tutorials are provided via cloud-based access to allow self-contained training of the trainees. A prospective multicentric validation study was conducted including seven surgical residents. Transferability of acquired skills to a RAS procedure were analyzed using the GEARS score. All participants successfully completed RoSTraC within 1 year. Transferability of acquired RAS skills could be demonstrated using a RAS gastroenterostomy on a synthetic biological organ model. GEARS scores concerning this procedure improved significantly after completion of RoSTraC (17.1 (±5.8) vs. 23.1 (±4.9), p < 0.001). In step 3 of RoSTraC, all participants performed a median of 12 (range 5-21) RAS procedures on the console in the operation room. RoSTraC provides a highly standardized and comprehensive training curriculum for RAS for surgical residents. We could demonstrate that participating surgical residents acquired fundamental and advanced RAS skills. Finally, we could confirm that all surgical residents were successfully and safely embedded into the local RAS team.

Defining benchmarks for robotic-assisted low anterior rectum resection in low-morbid patients: a multicenter analysis.

PURPOSE: To define the best possible outcomes for robotic-assisted low anterior rectum resection (RLAR) using total mesorectal excision (TME) in low-morbid patients, performed by expert robotic surgeons in German robotic centers. The benchmark values were derived from these results. METHODS: The data was retrospectively collected from five German expert centers. After patient exclusion (prior surgery, extended surgery, no prior anastomosis, hand-sewn anastomosis), the benchmark cohort was defined (n = 226). The median with interquartile range was first calculated for the individual centers. The 75th percentile of the median results was defined as the benchmark cutoff and represents the "perfect" achievable outcome. This applied to all benchmark values apart from lymph node yield, where the cutoff was defined as the 25th percentile (more lymph nodes are better). RESULTS: The benchmark values for conversion and intraoperative complication rates were ≤ 4.0% and ≤ 1.4%, respectively. For postoperative complications, the benchmark was ≤ 28% for "any" and ≤ 18.0% for major complications. The R0 and complete TME rate benchmarks were both 100%, with a lymph node yield of > 18. The benchmark for rate of anastomotic insufficiency was < 12.5% and 90-day mortality was 0%. Readmission rates should not exceed 4%. CONCLUSION: This outcome analysis of patients with low comorbidity undergoing RLAR may serve as a reference to evaluate surgical performance in robotic rectum resection.

[Robotic-assisted surgery of rectal cancer-Technique, limitations and results]. / Robotisch assistierte Chirurgie des Rektumkarzinoms ­ Technik, Limitationen und Ergebnisse.

BACKGROUND: The number of oncological robotic-assisted rectal cancer resections is rapidly increasing in Germany and worldwide; however, the indications, technique and potential limitations of this surgical technique are still discussed. MATERIAL AND METHODS: The standardized modular surgical technique, the results in our clinic and the currently published evidence are presented. RESULTS: The procedure should be divided into seven modules in terms of standardization and teaching. After the learning curve there are principally no limitations or contraindications. The robotic-assisted approach is superior to open surgery in the following points: blood loss, lymph node harvest, negative circumferential resection margin (CRM), complication rate and length of hospital stay. In comparison to conventional laparoscopy the conversion rate and postoperative sexual and bladder function disorders are decreased. The operating time is longer. CONCLUSION: Robotic-assisted rectal cancer resection is firmly established and standardized. The technique is superior to open surgery and conventional laparoscopy in some important aspects and is developing into the standard for this disease.

Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept.

BACKGROUND: Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable. METHODS: An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus. RESULTS: In order to provide a clear picture of the surgical anatomy, the "open book" model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure. CONCLUSION: Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME.

Analysis of albumin fatty acid binding capacity in patients with benign and malignant colorectal diseases using electron spin resonance (ESR) spectroscopy.

INTRODUCTION: In colorectal cancer (CRC), no biological marker is known that could serve both as a marker for detection and prognosis. Electron spin resonance (ESR) spectroscopy of spin-labeled fatty acid (FA) molecules binding to human serum albumin is a suitable method for the detection of conformational changes and alterations of transport function of albumin through changes in its FA binding capabilities. OBJECTIVE: The aim of this study was to examine whether the FA binding to albumin is detectably and significantly altered in CRC patients when compared with patients having benign colorectal diseases. MATERIALS AND METHODS: One hundred four patients operatively or endoscopically treated for CRC, sigmoid diverticulitis, or a colorectal adenoma were examined before procedure. Albumin was analyzed by ESR with spin-labeled FA. A determination ratio (DR) was calculated from the measured ESR spectra as ratios of the fraction of FA that is tightly bound vs. the fractions that are loosely interacting with albumin or are unbound. RESULTS AND DISCUSSIONS: Patients with CRC showed significantly lower DR values (DR, -0.09 +/- 0.98 vs. 0.61 +/- 1.43) than patients with benign colorectal diseases, consistent with a change of conformation and transport function of albumin in CRC. Within the CRC group, with advanced tumor stage, the difference in DR values increased. ESR of FA binding to albumin thus seems to be suitable for detection of patients with CRC. Furthermore, a correlation with advanced tumor stage can be established. CONCLUSIONS: These results suggest that a further evaluation of the role of ESR in patients with all stages of CRC should take place. It should also be examined whether ESR might play a role in detecting CRC in a larger panel of patients.

An expression module of WIPF1-coexpressed genes identifies patients with favorable prognosis in three tumor types.

Wiskott-Aldrich syndrome (WAS) predisposes patients to leukemia and lymphoma. WAS is caused by mutations in the protein WASP which impair its interaction with the WIPF1 protein. Here, we aim to identify a module of WIPF1-coexpressed genes and to assess its use as a prognostic signature for colorectal cancer, glioma, and breast cancer patients. Two public colorectal cancer microarray data sets were used for discovery and validation of the WIPF1 co-expression module. Based on expression of the WIPF1 signature, we classified more than 400 additional tumors with microarray data from our own experiments or from publicly available data sets according to their WIPF1 signature expression. This allowed us to separate patient populations for colorectal cancers, breast cancers, and gliomas for which clinical characteristics like survival times and times to relapse were analyzed. Groups of colorectal cancer, breast cancer, and glioma patients with low expression of the WIPF1 co-expression module generally had a favorable prognosis. In addition, the majority of WIPF1 signature genes are individually correlated with disease outcome in different studies. Literature gene network analysis revealed that among WIPF1 co-expressed genes known direct transcriptional targets of c-myc, ESR1 and p53 are enriched. The mean expression profile of WIPF1 signature genes is correlated with the profile of a proliferation signature. The WIPF1 signature is the first microarray-based prognostic expression signature primarily developed for colorectal cancer that is instrumental in other tumor types: low expression of the WIPF1 module is associated with better prognosis.

Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis.

BACKGROUND: Appendiceal perforation in patients with acute appendicitis may cause a variety of potentially life-threatening complications. Escherichia coli endotoxin has been shown to impact physiological bile flow in vivo. This had led to the theory that hyperbilirubinemia in patients with appendicitis may have a predictive potential for the preoperative diagnosis of appendiceal perforation. The aim of this retrospective study was to investigate the diagnostic value of hyperbilirubinemia as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis. METHODS: We identified 538 patients (306 female; 232 male, mean age, 35.6 y) with histologically proved acute appendicitis who underwent laparoscopic or conventional appendectomy between January 2004 and December 2007 in a surgical department of an academic teaching hospital. A retrospective multiple chart review of the medical records including laboratory values and histologic results was conducted. RESULTS: The mean bilirubin level of all patients was .9 mg/dL (+/-.6 SD mg/dL; range, .1-4.3 mg/dL; median, .7 mg/dL). Patients with appendiceal perforation, however, had a mean bilirubin level of 1.5 mg/dL (+/-.9 SD mg/dL; range, .4-4.3 mg/dL; median, 1.4 mg/dL), which was significantly higher than those with a nonperforated appendicitis (P < .05). The specificity of hyperbilirubinemia for appendiceal perforation was .86 compared with .55 for white blood count and .35 for C-reactive protein. Sensitivity was .7 compared with .81 for white blood count and .96 for C-reactive protein. CONCLUSIONS: Patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels.

An inflamed necrotic appendix epiploicum with immediate contact to a non-inflamed appendix vermiformis: a case report.

INTRODUCTION: Epiploic appendagitis is a rare cause of focal abdominal pain which, depending on its localisation, can mimic a variety of abdominal diseases. We describe a patient with an inflamed necrotic appendix epiploicum with immediate contact to a non-inflamed appendix vermiformis mimicking acute appendicitis. Considering the rare localization, this is the first report of this kind in the literature. CASE PRESENTATION: We present the case of a 50-year-old Caucasian man who presented with classic signs of acute appendicitis. On clinical exam, McBurney and Blumberg signs were positive. Additionally he had fever, leucocytosis (12/nl) and a slight increase in C-reactive protein (1 mg/dl). Based on the clinical presentation, the patient was taken to the operating room to perform an appendicectomy. Surprisingly, we found an inflamed necrotic appendix epiploicum, located immediately on a non-inflamed appendix vermiformis, which was ligated and excised. CONCLUSION: This case report demonstrates that epiploic appendagitis can mimic acute appendicitis on clinical exam and should be considered in the broad spectrum of abdominal disease presenting with right lower quadrant pain.

Surgical and medical emergencies on board European aircraft: a retrospective study of 10189 cases.

INTRODUCTION: In-flight medical and surgical emergencies (IMEs) onboard commercial aircrafts occur quite commonly. However, little epidemiological research exists concerning these incidents. METHODS: Thirty-two European airlines were asked to provide anonymous data on medical flight reports of IMEs for the years 2002 to 2007. The total number of incidents was correlated to revenue passenger kilometers (rpk). Additionally, on-board births and deaths, flight diversions, flight routes (continental/intercontinental) and involvement of a physician or medical professional in providing therapy were analysed. RESULTS: Only four airlines, of which two participated in this study, were able to provide the necessary data. A total of 10,189 cases of IMEs were analysed. Syncope was the most common medical condition reported (5307 cases, 53.5%) followed by gastrointestinal disorders (926 cases, 8.9%) and cardiac conditions (509 cases, 4.9%). The most common surgical conditions were thrombosis (47 cases, 0.5%) and appendicitis (27 cases, 0.25%). In 2.8% of all IMEs, an aircraft diversion was performed. In 86% of cases, a physician or medical professional was involved in providing therapy. A mean (standard deviation) of 14 (+/- 2.3, 10.8 to 16.6 interquartile range) IMEs per billion rpk was calculated. CONCLUSIONS: The study demonstrates that although aviation is regulated by a variety of national and international laws, standardised documentation of IMEs is inadequate and needs further development.

Carcinoma cunniculatum on the shoulder: an atypical localisation of a verrucous carcinoma.

Carcinoma cunniculatum is a rarely occurring type of verrucous carcinoma (VC) which is considered a low-grade variant of squamous cell carcinoma. The tumour usually appears in the oral, genitogluteal, and plantar region; however, potentially it can arise anywhere on the skin. Carcinoma cunniculatum on the shoulder is a very rare manifestation with only two cases being reported in the literature. In this communication we report a case of carcinoma cunniculatum on the left shoulder.

Cutaneous lesions of the external ear.

Skin diseases on the external aspect of the ear are seen in a variety of medical disciplines. Dermatologists, othorhinolaryngologists, general practitioners, general and plastic surgeons are regularly consulted regarding cutaneous lesions on the ear. This article will focus on those diseases wherefore surgery or laser therapy is considered as a possible treatment option or which are potentially subject to surgical evaluation.

Pancreatic carcinosarcoma. Case report of multimodal therapy and review of the literature.

CONTEXT: Carcinosarcoma (malignant mixed tumor) is a rare variant of a pancreatic neoplasm having a dismal prognosis; very few clinical data and treatment options have been published. Unlike adenocarcinoma of the pancreas, there is nothing specific in the literature for this variant regarding postoperative treatment with chemotherapeutic agents. CASE REPORT: We report the case of a 61-year-old woman presenting with anemia. Examination revealed a mass in the pancreatic head and she underwent a partial pancreaticoduodenectomy. Histopathological examination revealed a pancreatic neoplasm with both adenomatous as well as sarcomatous characteristics. Postoperatively, the patient was treated with gemcitabine and was in a good health for 9 months. Three follow-up CT scans were done, showing complete remission. Eleven months postoperatively, the patient died from a recurrence. CONCLUSION: Carcinosarcoma of the pancreas is a very rare disease having a dismal prognosis. In addition to reviewing the literature on this entity, we present the first published case where gemcitabine was administered as a treatment modality in combination with surgery.

Genome-wide expression patterns of invasion front, inner tumor mass and surrounding normal epithelium of colorectal tumors.

Colorectal tumors have characteristic genome-wide expression patterns that allow their distinction from normal colon epithelia and facilitate clinical prognosis. The expression heterogeneity within a primary colorectal tumor has not been studied on a genome scale yet. Here we investigated three compartments of colorectal tumors, the invasion front, the inner tumor mass, and surrounding normal epithelial tissue by microdissection and microarray-based expression profiling. In both tumor compartments many genes were differentially expressed when compared to normal epithelium. The sets of significantly deregulated genes in both compartments overlapped to a large extent and revealed various interesting known and novel pathways that could have contributed to tumorigenesis. Cells from the invasion front and inner tumor mass, however, did not show significant differences in their expression profile, neither on the single gene level nor on the pathway level. Instead, gene expression differences between individuals are more pronounced as all patient-matched tumor samples clustered in close proximity to each other. With respect to invasion front and inner tumor mass we conclude that the specific tumor cell micro-environment does not have a strong influence on expression patterns: largely similar genome-wide expression programs operate in the invasion front and interior compartment of a colorectal tumor.

Simultaneous ectopic adrenocorticotropic hormone syndrome and adrenal metastasis of a medullary thyroid carcinoma causing paraneoplastic Cushing's syndrome.

Medullary thyroid carcinomas (MTC) constitute about 5 to 7 % of thyroid neoplasms. They originate from parafollicular C-cells which can secrete adrenocorticotropic hormone (ACTH) and/or corticotropin-releasing factor (CRF) in abnormally high concentrations, potentially causing paraneoplastic Cushing's Syndrome (CS). We report on a 42-year-old male patient with a ten year history of metastatic medullary thyroid carcinoma suffering from paraneoplastic Cushing's Syndrome caused by ectopic hypersecretion of ACTH and a simultaneous Cortisol producing adrenal metastasis.

Epiploic appendagitis--clinical characteristics of an uncommon surgical diagnosis.

BACKGROUND: Epiploic appendagitis (EA) is a rare cause of focal abdominal pain in otherwise healthy patients with mild or absent secondary signs of abdominal pathology. It can mimick diverticulitis or appendicitis on clinical exam. The diagnosis of EA is very infrequent, due in part to low or absent awareness among general surgeons. The objective of this work was to review the authors' experience and describe the clinical presentation of EA. METHODS: All patients diagnosed with EA between January 2004 and December 2006 at an urban surgical emergency room were retrospectively reviewed by two authors in order to share the authors' experience with this rare diagnosis. The operations were performed by two surgeons. Pathological examinations of specimens were performed by a single pathologist. A review of clinical presentation is additionally undertaken. RESULTS: Ten patients (3 females and 7 males, average age: 44.6 years, range: 27-76 years) were diagnosed with symptomatic EA. Abdominal pain was the leading symptom, the pain being localized in the left (8 patients, 80 %) and right (2 patients, 20%) lower quadrant. All patients were afebrile, and with the exception of one patient, nausea, vomiting, and diarrhea were not present. CRP was slightly increased (mean: 1.2 mg/DL) in three patients (33%). Computed tomography findings specific for EA were present in five patients. Treatment was laparoscopic excision (n = 8), excision via conventional laparotomy (n = 1) and conservative therapy (n = 1). CONCLUSION: In patients with localized, sharp, acute abdominal pain not associated with other symptoms such as nausea, vomiting, fever or atypical laboratory values, the diagnosis of EA should be considered. Although infrequent up to date, with the increase of primary abdominal CT scans and ultrasound EA may well be diagnosed more frequently in the future.

Combination of surgical excision and custom designed silicon pressure splint therapy for keloids on the helical rim.

Keloids are defined as dermal fibrotic lesions which are considered an aberration of the wound healing process. Their etiology and pathogenesis are poorly understood. Different treatment modalities are described in the literature depending on the morphology and size of the keloid. We report a case of a large ear keloid on the helical rim which was successfully treated with surgery and a custom designed silicon pressure clip.