Background/Aim: As opportunities for hands-on surgical training during residency have decreased, off-thejob training before surgery is gaining importance. We developed a training program using a box-trainer for surgical residents. This study aimed to verify the effectiveness of the program. Using task-achievement time, we demonstrated the learning curve through continuous task training and verified the efficiency of our training tasks. In addition, we examined the circularity of the cut circle to evaluate the task accuracy and summarized the questionnaire results. Patients and Methods: A prospective, observational study was conducted at a single center with five trainees from April 2019 to March 2020. The training consisted of four tasks based on the Fundamentals of Laparoscopic Surgery module. The trainees had to achieve expert proficiency time targets. The task-achievement time and circularity of the cut circle were used for objective assessment; subjective evaluation was done using a questionnaire. Results: Although the learning curves of the task-achievement time seemed to reach a plateau between the third and the fifth skills lab, all the trainees achieved expert proficiency times for the three tasks. Circularity of the cut circle tended to be more accurate after training. All trainees perceived an improvement in their skills after the training program. The level of satisfaction of the training program was rated as 'very satisfied' or 'satisfied'. Conclusion: Continuous box-trainer training for 1 year may be effective for improvement in preoperative laparoscopic surgical skills of surgical residents. Opportunities for hands-on surgical training during residency have decreased in recent times (1). However, because minimally invasive surgery has become a mainstream practice within general surgery, off-the-job training before performing surgery on patients is gaining importance (1). The performance of surgeons under the fundamentals of laparoscopic surgery (FLS) program, launched as a preoperative training module by the Society of Gastrointestinal and Endoscopic Surgeons, has been shown to correlate with intraoperative performance during laparoscopic surgery (2-4). This program incorporates training tasks using box-trainers to teach the surgical skills fundamental to laparoscopic surgery (2). The program sets a proficiency time with allowable errors as a task goal and also provides a recommended training schedule (5). Through this program, including goal-oriented training and scheduled practice, trainees can achieve proficiency standards, resulting in skill retention and decreased performance variation (6-9).The FLS program involves five tasks, namely peg transfer (PT), precision cutting (PC), ligation loop, suture with extracorporeal knot, and suture with intracorporeal knot (IK) (2). These tasks were developed to train laparoscopic coordination skills, the use of certain laparoscopic instruments, and particular laparoscopic techniques (10). However, since the equipment and supplies used for the standard FLS t...

Hybrid surgery (abdominal robotic approach with a trans-anal approach) has been reported to improve oncological outcomes in cases involving advanced cancer or technical difficulties. A 74-year-old woman presented with anal pain and stenosis. Examination revealed palpable sclerosis on the anterior wall at the anal verge with possible vaginal invasion. A biopsy revealed an adenocarcinoma. We performed a two-team robot-assisted abdominoperineal resection combined with resection of the vagina supported by a simultaneous trans-perineal approach. After rendezvous at the posterior side, the abdominal team cut the posterior wall of the vaginal vault while the perineal team confirmed the surgical margin. Histopathological findings identified the tumour as an anal gland adenocarcinoma (pT4b [vagina] N0M0 pathological stage IIC) with a negative circumferential resection margin. Hybrid surgery combined with resection of the posterior wall of the vagina may be performed safely and is a valuable surgical option for multimodal treatment of anal adenocarcinomas.

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