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Improving Patient Outcomes with Minimally Invasive Surgery

Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.




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Vol. 8 No. 36


This month’s issue features an interview with our MISS Co-Directors and 2020 Faculty Bradley Davis, Scott Shikora, and Jaime Ponce. These thought leaders devoted their time to discuss teaching and training our residents on multiple platforms, challenges in training residents, and social media as a tool or a weapon in teaching.

I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders in surgical research and innovation. Thank you to these doctors for sharing their thoughts and opinions with us, and also to all of this month’s contributors!

Happy New Year from all of us at MISS!


Colleen Hutchinson

What are the most effective tools in teaching and training today, in a climate and environment where there are multiple surgical approaches to learn?

Dr. Scott Shikora: I have come to believe that adequate training cannot be performed with a single tool or modality.  Due to the complexity of bariatric surgery and the ever-growing number of interventions that can be offered, the trainee must rely on many tools.  For example, surgical trainees need to be able to perform open, laparoscopic, robotic, and endoscopic techniques.  Therefore, unlike surgery in the past, where all skill development was done in the operating room by an attending who took a resident through the case, today’s surgeons—and those of the future—will need to also spend time in the skills lab putting hours into acquiring appropriate skills with endoscopes, robots, and laparoscopes.  In addition to simulation, the resident of today has access to massive libraries of published articles and videos that can also be of value for training.

Dr. Brad Davis: Experience in the operating room continues to be the most effective way to train residents on surgical techniques, which demonstrates how far behind we are from most skill-based
industries. Simulation is an adjunct but is not yet good enough or affordable to offer any considerable boost in performance. What are needed are better tools at the front end to help medical students understand their aptitude for a career in surgery. The conventional wisdom of my mentors was that “I can train anyone how to operate.” That is simply not true anymore with the explosion in technologies and techniques and the subsequent strain on the learner to assimilate all of the skills necessary. Now more than ever we need better, higher fidelity tools to allow the learner to truly work in a virtual world. This technology has to be affordable and available to students and residents.

Dr. Jaime Ponce: I think the future of training will be simulators. As the technology improves, and many different case scenarios are incorporated, simulators allow surgeons facing a new technique
and technology learn it, and then practice and practice before they can face a real patient. I think that is also one of the great advantages of robotic surgery, as this complex computer can simulate and allow residents and new surgeons to learn tasks like suturing, tying knots, dissection on difficult case scenarios, etc., much more easily. New devices and procedures will have to incorporate a simulation case scenario to enable easier learning of the tasks necessary to proceed in real patients.
What is the biggest challenge today in training residents?

Dr. Scott Shikora: I believe the biggest challenge to training residents is the lack of time available for training.  Residents have significant clinical responsibilities both in and out of the operating room that can potentially compromise the time necessary to adequately train.  This is exacerbated by the present work hour restrictions that leave many residents deficient in experience.  Additionally, the significant and growing requirements for documentation further reduce the time available for training.

Dr. Brad Davis: In the last 20 years, the surgical workforce and resident compliment has become more diverse – which is to the betterment of our patients and our specialty. However, we have not adapted to the diversity of learning styles and aptitudes. The time-based, quantitative nature of training is no different than it has been for the last 100 years. None of this takes into account the
unique skills and needs of our learners. We need better assessment tools to understand where each resident is along his or her individual learning curve and eliminate metrics like number of cases to
secure a graduation certificate. With tools like the “black box” in the robotics platforms, we can start to get more objective data on resident performance in skills acquisition and can develop a
predetermined competency level, which would allow a resident to be “credentialed” doing a certain procedure. These tools need to be more widespread and available in all of our MIS and open
platforms. The ability of a surgeon to objectively score a resident’s performance is varied, and we need to do better to ensure that all of our residents achieve the appropriate competencies.

Dr. Jaime Ponce: The biggest challenge is the need to be “productive” and “efficient” in a day, with different distractors including EMRs and OR time. Teaching includes dedicating time to allow the
residents to perform tasks and techniques of all or part of the procedure, and initially will imply spending more time to teach and correct the residents while doing their first cases. That is why I think that simulators will be the future for residents to repeatedly practice before they face real patients for the first time, and this will allow them to improve their skills and ability to be more efficient in their learning curve on patients.
Has social media become more of an educational tool than a weapon for practicing general surgeons who seek to learn new techniques and procedures?

Dr. Jaime Ponce: Social media can be an educational tool, but it is important to understand that the book step-by-step will not be there for the most part. It will be an interesting tool for learning
refining points, facing unusual cases, handling difficult situations, and maybe learning the highlights of new techniques. But learning surgery still as of today requires face-to-face with a teacher, additional tools like animal lab or cadaver assistance, and simulators.

Dr. Brad Davis: I am not sure how social media is playing out in terms of surgeons learning a new technique or procedure. I think it is valuable to have resources for surgeons to converse and be exposed to expert level performances, but watching a clip of an expert performing a complex case does not substitute for proper training and credentialing. Social media is not peer-reviewed.

Dr. Scott Shikora: Social media has become both an educational tool and a weapon for practicing general surgeons who seek to learn technique and procedures.  While there is a wealth of information in social media that may be of benefit, social media is unregulated and the contents are not peer-reviewed. Therefore, general surgeons seeking to learn new techniques and procedures may be exposed to biased material and data, or even be encouraged to perform procedures above their skill sets.

Suggested Readings


Article: Safety and short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report from a multicenter study. Neto MG, Moon
RC, de Quadros LG, Teixeira AF, et al. Surg Endosc. 2019 Oct 17. [Epub ahead of print]

Dr. Galvao Neto: Endoscopic sleeve gastroplasty (ESG) is an endobariatric therapy that is gaining traction worldwide as a treatment for obesity with promising results on safety and efficacy. In this new article, some of the Brazilian experience with the method is presented with 233 patients with Class I and II obesity, mean age and BMI of 41.1 years and 34.7 kg/m 2 , respectively, and a population of 73% female. The 123 patients who reached a 12-month follow-up had a mean 19.7% total weight loss (TWL). Safety analysis of the whole series reveals only one serious adverse event and no reported deaths. While ESG published literature presents quite some variation on suture pattern, this paper is based on the experience of a group of physicians trained by a single proctor that used the same technique in all cases. Gathered global experience on ESG allowed at least four meta-analyses to be published, and series like this one reinforce its promising results. An FDA randomized controlled trial is currently being performed to solidify it.



Article: Predictive factors and risk model for positive circumferential resection margin rate after transanal total mesorectal excision in 2653 patients with rectal cancer. Roodbeen SX, de Lacy FB, van Dieren S, et al. Ann Surg. 2019 Nov;270(5):884-891.

Dr. Alexander Hawkins: Transanal total mesorectal excision (TaTME) has been recently developed to increase the quality of surgical resection and improve oncological outcomes, particularly in patients with low rectal cancers. So how are we doing? This study looks at 2,653 patients out of a prospective registry and finds an outstanding overall circumferential resection margin (CRM) positivity rate of just 4%. A positive CRM after TaTME was significantly associated with tumors located up to 1 cm from the anorectal junction, anterior tumors, cT4 tumors, extra-mural venous invasion (EMVI), and threatened or involved CRM on baseline MRI. These are all features that we would expect to threaten any CRM regardless of technique. While the potential for selection bias exists in this study, the data overall shows that we are on the right track with this technique.



Article: Does sleeve gastrectomy expose the distal esophagus to severe reflux?: a systematic review and meta-analysis. Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian H. Ann Surg. 2019 Mar 20.  [Epub ahead of print]

Rees Porta: Authors from the United Kingdom performed a meta-analysis on 46 studies from 2000 – 2018 which included 10,718 patients. While a meta-analysis won’t answer the questions of etiology or prevention, it does give good numbers for counseling patients. They showed de novo GERD in 20% of patients, worsening of GERD in 19%, esophagitis in 28%, and Barrett’s in 8% despite a mean EBWL of 61%. Interestingly, endoscopic findings of esophagitis and/or Barrett’s did not correlate well with symptoms.


Article: Mortality after bariatric surgery: findings from a 7-year multicenter cohort study.

Dr. Robert Lim: This is a very exciting article as it lends more credence that bariatric surgery improves life expectancy in obese patients. While it does not have the long-term follow up of the Swedish obesity studies, it does address the fact that those studies were in a very homogenous society and perhaps less applicable to the general population. On the other hand, there is a very concerning finding of the higher than expected mortality at 5-7 years after surgery.




Vol. 8 No. 35


This holiday month’s issue features an interview with our MISS Co-Directors Aurora Pryor, Bradley Davis, and Guy Voeller. These thought leaders devoted their time to discuss some issues surrounding emerging technologies, MISS 2020, the state of FDA clearance path, and work-related challenges.

I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders in surgical research and innovation. Thank you to these doctors for sharing their thoughts and opinions with us, and also to all of this month’s contributors, especially our newest—Dr. Alexander Hawkins, from Vanderbilt University Medical Center’s Division of General Surgery, Colon & Rectal Surgery. Happy Holidays from all of us at MISS!


Colleen Hutchinson

What has been one of your biggest work-related challenges this year and how have you addressed it?

Guy Voeller: I am a busy clinical surgeon, so I operate 5 days a week with office hours 2 half days. When my day is done and I have rounded and tucked everyone in for the night, I go home and sit down at the computer to do billing for the day and to get charts ready for the next day. The scourge of the EMR! My biggest challenge is thus finding enough time to complete the day and be ready for the next. I think this is a problem for all busy surgeons today and I have not figured out a way to address this problem.

Brad Davis: One of the biggest challenges we face in our healthcare system is the increasing utilization of the hospital resources. We are strained in terms of OR availability and hospital beds. I believe this is an increasing trend as populations of large cities grow and the infrastructure has not kept up. In addition, patients are presenting with more complexity and minimally invasive surgery remains an important aspect of their care – it just takes longer and as such further puts a strain on resources.

Aurora Pryor: This has been a year of mastering work-life-society balance for me as President of SAGES. I am very lucky to have great partners in all three that have helped to enable my success (Thank you!!!). I think growing your support systems in lighter years enables you to keep up when you have less flexibility.

What about the specific MISS program that you oversee as Co-Director will be valuable to attendees?

Brad Davis: For the Colon program, we have a lot of great content as always. There have been several new publications related to bowel preps and the role of enhanced recovery in colorectal surgery, with a recent update from the ERAS society. In addition, we will discuss robotics and its role in colorectal surgery, as well as what’s new coming down the pipeline of innovation that will benefit our patients.
Guy Voeller: The Hernia session of MISS again has the leading authorities in herniology as faculty. We have an interesting session on coding and billing to properly maximize reimbursement, another session on whether Botox for hernia repair is a fad or here to stay, an excellent “debate” on robotics in hernia repair, and many other great sessions. It promises to have all the energy and controversy for which it’s become known.

Aurora Pryor: MISS is a great meeting to think a bit outside of the box from more mainstream meetings. We are getting to focus on clinical care and new opportunities in Foregut. I think every surgeon will find something new to bring home and implement from the meeting.

What are the most promising emerging technologies and/or techniques and procedures that you are excited about in your area of surgery?

Aurora Pryor: I have started incorporating a falciform flap into some of my more difficult paraesophageal hernia repairs. At a time and in a location where the use of mesh is questioned, a nice native tissue alternative for tissue reinforcement is appreciated. Fred Brody and Adrian Park introduced this technique to me, and I think it should be in the toolbox of every foregut surgeon.

Brad Davis: Always looking to see what the newest robotic platforms are going to bring. In addition to creating a more competitive market, which should help drive down costs, the partnerships currently out there have great potential to begin solving the next big problems. Machine learning and predictive analytics built in to some of these platforms will allow for greater safety and better outcomes.

Guy Voeller: In my area of surgery (general), it appears most of the focus on emerging technologies centers around robotic platforms and virtual reality for surgery. When these technologies are combined in an effective way, it will lead to some tremendous changes in the way surgery is done. Apparently competition for the Da Vinci robot is around the corner, and it will be interesting to see how hospitals, surgeons, and training programs deal with this situation. I don’t know what promise the new platforms will hold, but it will be extremely disruptive to be sure.

How would you characterize the current climate and process of obtaining FDA clearance for such new advances?

Guy Voeller: I think the FDA is under scrutiny due to the number of lawsuits regarding permanent synthetic mesh products. All of the mesh companies are paying millions and millions of dollars to defend these lawsuits and there is no end in sight. The 510K process has led to this problem. The Europeans now must go through a much more rigorous process for device approval that will require expensive clinical studies in order to obtain a CE mark (certification mark) to sell new products. I can foresee something similar coming to America. I think this will lead to significant changes in new technology introduction. Some of this will be good and some of it will be bad. The “climate” is thus a
hot mess.

Aurora Pryor: There has been some progress in getting new technology through the FDA, but I am frustrated that some new and effective technologies are struggling to gain traction (and reimbursement) after approval. I am working with SAGES this year to try to improve the reimbursement pathway for new technologies. These things help our patients by offering less invasive or more effective care. If we want to improve on what we do, this process must be optimized.


Suggested Readings


Article: Brazilian intragastric balloon consensus statement (BIBC): practical guidelines based on experience of over 40,000 cases. Neto MG, Silva LB, Grecco E, et al. Surg Obes Relat Dis. 2018 Feb;14(2):151-159.

Dr. Galvao Neto: Intragastric balloons are by far the oldest endobariatric therapy (EBT), with around 20 years of clinical practice outside the US, but were just recently (2015) FDA-approved in the US. This Brazilian balloon consensus paper gives us the opportunity to understand how this therapy performs in a clinical setup among experts. 40,000+ cases is an impressive number, and this consensus—done under Delphi method—solidifies the intragastric balloon method and its clinical practice with regard to patient selection, preparation, multidisciplinary approach, technique, results and complications. The paper also serves as a guideline of practical recommendations for achieving good results.



Article: Intracorporeal or Extracorporeal ileocolic anastomosis after laparoscopic right colectomy: a double-blinded randomized controlled trial. Allaix ME, Degiuli M, Bonino MA, et al. Ann Surg. 2019 Nov; 270(5):762-767.

Dr. Alexander Hawkins: An intracorporeal anastomosis after laparoscopic right hemicolectomy has a number of theoretical advantages- decreased hernia rate from the opportunity to place the extraction site anywhere in the abdomen, less mesenteric traction, and the ability to easily perform in iso-peristaltic anastomosis. This trial randomized 140 patients to either intra- or extra- corporeal anastomoses after a laparoscopic right hemicolectomy. Powered to compare length of stay (median of 6 days in this European study), they observed earlier recovery of postoperative bowel function in the incorporeal group, but no difference in length of stay. No other pathological or clinical differences were observed. Somewhat ominous was the non-significant difference in leak rate (Intra-8.7% vs Extra-2.9%; p=0.27). Overall, this is a well-done study that does little to settle the debate.



Article: Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis. Bakker WJ, Aufenacker TJ, Boschman JS, Burgmans JPJ. Surgery. 2019 Oct 28. [Epub ahead of print]

Dr. Luke Funk: The type of mesh a surgeon uses during an open inguinal hernia repair with mesh (Lichtenstein technique) may influence recurrence and inguinodynia rates. In this study, the authors conducted a meta-analysis that included data from 21 randomized controlled trials studies and more than 4,000 patients. The investigators found that use of lightweight mesh (<50 g/m 2 ) compared to heavyweight mesh (>70 g/m 2 ) reduced the risk of experiencing “any pain” after hernia surgery and the risk of experiencing a foreign body sensation. There were no differences in recurrence rates or severe pain rates between the two groups. The authors concluded that lightweight mesh is preferred for open inguinal hernia repair with mesh. These findings are notable given that the Lichtenstein repair is the most common type open inguinal hernia repair performed.



Article: Eating self-efficacy as predictor of long-term weight loss and obesity- specific quality of life after sleeve gastrectomy: A prospective cohort study. Fiolo TN, Tell GS, Kolotkin RL, et al. Surg Obes Relat Dis. 2019 Feb;15(2):161-167.

Dr. Robert Lim: This is an important paper that shows how eating behaviors affect bariatric surgery success. It is something that bariatric surgeons have felt all along but there is scarce literature on this topic. Not only does better eating self-efficacy lead to more weight loss, it also appears to allow for more durable weight loss.



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