Su1463 Simulated NOTES® Sigmoidectomy Training Improves the Responsiveness Over Time of Surgical Endoscopists

Su1463 Simulated NOTES Sigmoidectomy Training Improves the Responsiveness Over Time of Surgical Endoscopists Jonathan Buscaglia*, Seth A. Stein, Nicholas Palladino, Joshua Karas, Paula Denoya, Juan Carlos Bucobo, Satish Nagula, Muath Bishawi, Roberto Bergamaschi Medicine, Stony Brook University, Stony Brook, NY; Surgery, Stony Brook University, Stony Brook, NY Background: Transanal sigmoid colon resection by natural orifice transluminal endoscopic surgery (NOTES) may be a feasible clinical procedure if performed by highly-skilled, trained endoscopists. A model and training protocol has yet to be established for a completely incissionless NOTES sigmoidectomy. Objective: 1) to develop a model for simulated NOTES sigmoidectomy training; 2) to validate the model by assessing the responsiveness of endoscopists over time during a series of training sessions. Methods: Attending endoscopists (2 colorectal surgeons, 2 interventional gastroenterologists) underwent simulated NOTES sigmoidectomy training using disposable abdominal trays with tattooed sigmoid cancers in a hybrid simulator model (Fig 1). The 8-step standardized technique was performed transanally with a double-channel therapeutic upper endoscope, a single adult colonoscope, endoscopic hemoclips, & endoscopic scissors in the following order: 1) viscerotomy with balloon dilation from the rectum; 2) retroperitoneal access/dissection; 3) left ureter identification, inferior mesenteric artery and vein division; 4) colonoscopy to the right colon to provide traction & aide in subsequent splenic flexure mobilization; 5) flexure mobilization; 6) left colon and rectal mobilization; 7) transanal specimen transection; 8) extracorporeal colorectal anastomosis. After a baseline testing procedure, endoscopists underwent 4 training sessions mentored by an expert surgical endoscopist before proceeding to an unmentored final test with predetermined proficiency criteria. Responsiveness was defined as change in performance over time, & was assessed by comparing baseline testing with unmentored final test times. Results: 4 physicians successfully completed 21 resections. Tumors were located at a median distance of 29.2cm from the anal verge (range 26-32.5). Overall, there was a 42% reduction in total operating time (median 127.5v74min, p 0.068). A non-significant trend towards improvement in median time values (in min) was noted for the following variables: successful viscerotomy (17.5v9,p 0.197), access to retroperitoneum (21.5v11.5,p 0.144), identification/ligation of ureter/vessels (9v0.5,p 0.068), colonoscopy (4.5v3.5, p 0.655), mobilization of splenic flexure (19.5v10, p 0.144), mobilization of left colon (20v14.5, p 0.461), specimen retrieval (9.5v8.5,p 0.465), & creation of anastomosis (14v11,p 0.715). During training there were 2 conversions to laparotomy (9.5%) due to left iliac artery injury and colonic perforation. No complications occurred during final test procedures. Conclusions: Simulated NOTES sigmoidectomy training is feasible and impacted responsiveness in attending physicians with a 42% reduction in operating time. Further studies are warranted to assess the utility of simulator training when NOTES sigmoidectomy is performed in human models.