Surgeon Quality Control and Standardization of D2 Lymphadenectomy for Gastric Cancer

Objective: To qualify surgeons to participate in a randomized trial comparing laparoscopic and open distal D2 gastrectomy for advanced gastric cancer. Summary of Background Data: No studies have sought to qualify surgeons for a randomized trial comparing laparoscopic and open D2 gastrectomy for advanced gastric cancer. Methods: We conducted a multicenter prospective observational study evaluating unedited videos of laparoscopic and open D2 gastrectomy performed by 27 surgeons. Surgeons performed 3 of each laparoscopic and open distal gastrectomies with D2 lymphadenectomy for gastric cancer. Five peers reviewed each unedited video using a video assessment form. Based on experts’ review of videos, a separate review committee decided surgeons as “Qualified” or “Not-qualified.” Results: Twelve surgeons (44.4%) were qualified on initial evaluation whereas the other 15 surgeons were not. Another 9 surgeons were finally qualified after re-evaluation. The median score for Qualified was significantly higher than Not-qualified ( P < 0.001). Significant differences between Qualified and Not-qualified were noted both in operation type and in all evaluation area of surgical skill, perigastric, and extra-perigastric lymphadenectomy, although the inter-rater variability of the assessment score was low (kappa = 0.285). However, Not-qualified surgeons’ scores improved upon re-evaluation of resubmitted videos. When compared laparoscopy with open surgery, median scores were similar between the 2 groups ( P = 0.680). However, open gastrectomy scores for surgical skills were significantly higher than for laparoscopic surgery ( P = 0.016). Conclusions: Our surgeon quality control study for gastrectomy represents a milestone in surgical standardization for surgical clinical trials. Our methods could also serve as a system for educating surgeons and assessing surgical proficiency.