窪木 大悟

BACKGROUND: Performing laparoscopic suturing requires quality education. Differences in instruction according to trainer surgeon specialty could affect trainee skill acquisition. This study compares the focus of feedback between Upper gastrointestinal (UGI) specialists and Colorectal (CR) specialists. METHODS: A 13-year postgraduate trainee received online feedback for two laparoscopic suturing procedures videos of "low" and "high" difficulty from 16 surgeons (UGI = 8, CR = 8) who are specialists in laparoscopic surgery and qualified by the Endoscopic Surgical Skill Qualification System of the Japan Society for Endoscopic Surgery. The number of feedback comments was compared between specialist groups for grasping the needle, needle driving, knot tying preparation, and knot tying. Both groups were also surveyed regarding suturing procedures. RESULTS: The UGI group had significantly more feedback comment varieties for knot tying preparation during the "high" difficulty video (UGI 4.0 ± 2.1 (mean ± SD), CR 1.9 ± 1.4, p < 0.05). According to questionnaire results, the UGI group performed suturing more routinely than the CR group, was more confident, and less stressed about the procedure. CONCLUSION: In feedback for laparoscopic suturing videos, the UGI group focused more on the preparatory stage for knot tying than the CR group. This indicates that comment focus differs according to specialty, suggesting that instruction from trainers of multiple specialties is optimal. KEY MESSAGE: In this study, it was shown that the focus of feedback on laparoscopic suturing procedures differs according to the surgeon's subspecialty. These insights could have important implications for optimizing laparoscopic training programs.

INTRODUCTION: Median Arcuate Ligament Syndrome (MALS) is a condition in which the median arcuate ligament tightly compresses the celiac artery. A patient presented with MALS and segmental adenomyomatosis of the gallbladder, both treated simultaneously using a laparoscopic approach. PRESENTATION OF CASE: A 48-year-old male with adenomyomatosis of the gallbladder presented with postprandial epigastric pain. Abdominal three-dimensional computed tomography scan showed compression of the celiac artery, and the patient was diagnosed with MALS. Laparoscopic dissection of the median arcuate ligament and cholecystectomy were performed to treat both conditions. By optimizing port positions, both conditions could be treated simultaneously. The patient was discharged on postoperative day 6 and has no recurrent symptoms 20 months postoperatively. DISCUSSION: To the best of our knowledge, there are no previously reported cases of simultaneous laparoscopic division of the median arcuate ligament and cholecystectomy. CONCLUSION: By optimizing the port positions, laparoscopic division of the median arcuate ligament and cholecystectomy were performed simultaneously, minimally invasively, safely and effectively.

OBJECTIVE: A system to provide feedback for laparoscopic training using an online conferencing system during the COVID-19 pandemic was developed. The purpose of this study is to evaluate this system from the trainer perspective. DESIGN: A procedural feedback system using an online conferencing system was devised. SETTING: Surgical training was observed using an online conferencing system (Zoom). Feedback was provided while viewing suture videos which are, as a feature of this system, pre-recorded. Feedback was then recorded. Trainer comments were then converted into text, summarized as feedback items, and sorted by suture phase which facilitates reflection. Trainers completed a questionnaire concerning the usability of the online feedback session. RESULTS: Eleven trainers were selected. Physicians had an average experience of 21.9 ± 5.9 years (mean ± standard deviation). The total number of feedback items obtained by classifying each phase was 32. Based on questionnaire results, 91% of trainers were accustomed to the use of Zoom, and 100% felt that online procedural education was useful. In questions regarding system effectiveness, more than 70% of trainers answered positively to all questions, and in questions about efficiency, more than 70% of trainers answered positively. Only 55% of the trainers felt that this system was easy to use, but 91% were satisfied as trainers. CONCLUSIONS: The results of the questionnaire suggest that this system has high usability for training. This online system could be a useful tool for providing feedback in situations where face-to-face education is difficult.

INTRODUCTION: Gastric adenocarcinomas with low grade atypia may be difficult to diagnose as gastric cancer by preoperative biopsy. We report an extremely well-differentiated adenocarcinoma (EWDA) of the stomach which appeared like a submucosal tumor diagnosed by preoperative endoscopic submucosal dissection. PRESENTATION OF CASE: A 70-year-old male was referred with a 3-month history of a submucosal-appearing lesion in the gastric wall found on endoscopy. Biopsies of the lesion were performed and were inconclusive for neoplasia. Endoscopic ultrasonography showed a low echoic tumor growing into the fourth layer of the gastric wall. It was difficult to identify the tumor by repeat biopsy. Endoscopic submucosal dissection of the lesion was performed and revealed adenocarcinoma, and laparoscopic total gastrectomy was performed. Histopathologic evaluation showed that the tumor was stage IIA (T3N0M0). There is no recurrence 12 months after resection. DISCUSSION: Gastric EWDAs are rare lesions, accounting for 0.6% of all gastric cancers. It is difficult to diagnose gastric EWDA especially if it appears like a submucosal tumor. This lesion was finally diagnosed by endoscopic submucosal dissection. CONCLUSION: Endoscopic submucosal dissection may facilitate establishing the preoperative diagnosis of a tumor thought to be a gastric EWDA based on its endoscopic appearance and pathological findings.