Surgical Innovation recent issues

Laparoscopic Parastomal Hernia Repair: A Description of the Technique and Initial Results

2008-05-20

In this study, the authors review their initial results with the laparoscopic approach for parastomal hernia repair. Between 2006 and 2007, 4 patients were treated laparoscopically at our institution. The hernia sac was not excised. A piece of Gore-Tex DualMesh with a central keyhole and a radial incision was cut so that it could provide at least 3 to 5 cm of overlap of the fascial defect. The mesh was secured to the margins of the hernia with circumferential metal tacking and trans-fascial sutures. No complications occurred in the postoperative period. After a median follow-up of 9 months, recurrence occurred in 1 patient. This was our first patient in whom mesh fixation was performed only with circumferential metal tacking. The laparoscopic repair of parastomal hernias seems to be a safe, feasible and promising technique offering the advantages of minimally-invasive surgery. The success of this approach depends on longer follow-up reports and standardization of the technical elements.

Polyester Composite Mesh for Laparoscopic Paraesophageal Hernia Repair

Varela, E., Hinojosa, M., Nguyen, N. T. — 2008-05-20

Recent evidence supports the use of prosthetic reinforcement material during laparoscopic hiatal hernia repair; however, the search for appropriate prosthetic materials is still under investigation. In this article, the technical feasibility and the short-term outcomes of the use of polyester composite mesh for crural reinforcement was determined. A small series of patients with large paraesophageal hiatal hernias underwent laparoscopic repair with mesh (5 males; mean age = 62 ± 10 years; mean body mass index = 29 ± 1 kg/m², and mean American Society of Anesthesiologists = 3 ± .4). There were no postoperative complications, deaths, or evidence of hernia recurrence documented by barium study at a median follow-up of 9 months. The use of the polyester composite mesh is technically feasible, has excellent intracorporeal handling characteristics, and holds suture readily. The short-term outcomes of the use of the polyester composite mesh for paraesophageal hernia repair reinforcement appeared to be favorable and are encouraging.

Transumbilical Endoscopic Cholecystectomy With the Trichannel Trocar Technique: A Porcine Feasibility Study

Jiang Fan Zhu, , Ying Zhang Ma, , Jin Ling Yu, , Hai Hu, — 2008-05-20

The aim of this study is to verify the feasibility of another option: transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. Eight domestic pigs were submitted to transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. A fine grasper of 2 mm in diameter was inserted through a small skin incision on the right upper abdomen for grasping the gallbladders. The natural scar of the umbilicus was restored after extract of the specimen. All the gallbladders were removed successfully without severe bleeding during dissection, intraoperative, and postoperative complications. Postmortem examination revealed that the gallbladder fossa was clean, the clips on the cystic duct and artery were secure, and neither bile nor blood leakage was found at the operative field. The feasibility and safety of transumbilical endoscopic cholecystectomy are demonstrated by this study. It is possible to use this approach in patients with gallbladder diseases.

Prevention of Trocar Site Hernias: Description of the Safe Port Plug Technique and Preliminary Results

2008-05-20

The aim of this study was to describe a new technique to prevent the development of incisional hernias in trocar sites. Between March and June 2006, a pilot study was conducted to determine the feasibility of the safe port plug technique using the Bioabsorbable Hernia Plug to prevent incisional hernia in trocar sites. The device was implanted in the umbilical trocar site (10-11 mm) of 17 patients undergoing laparoscopic surgery during the study period. The mean follow-up of patients was 14.6 months. Implantation of the Bioabsorbable Hernia Plug device by the safe port plug technique was possible in all cases. No patient presented complications in the follow-up. Our preliminary experience suggests that this technique is simple and feasible, and we hypothesized that this technique could be superior to conventional fascial closure: a hypothesis that must be proven in a randomized prospective trial that is currently in progress.

Decision-making Algorithm for the STARR procedure in Obstructed Defecation Syndrome: Position statement of the group of STARR Pioneers

2008-05-20

Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as obstructive defecation syndrome. However, there is still no clear evidence whether the stapled transanal rectal resection (STARR) procedure provides a safe and effective surgical option for symptom resolution in patients with obstructive defecation syndrome, as evidence-based guidelines and functional long-term results are still missing. On the basis of the need for objective evaluation, a European group of experts was founded (Stapled Transanal Rectal Resection Pioneers). Derived from 2 meetings (October 26-28, 2006, Gouvieux, France and November 28-29, 2007, St Gallen, Switzerland) a concept for treatment options in patients suffering from obstructive defecation syndrome was developed, including a clear decision-making algorithm specifically focusing on the role of the stapled transanal rectal resection procedure based on clinical symptoms and dynamic imaging and inclusion and exclusion criteria for the stapled transanal rectal resection procedure.

Laparoscopic Treatment of Complex Small Bowel Obstruction: Is It Safe?

2008-05-20

Laparoscopic treatment of small bowel obstruction has many reported advantages, yet it is infrequently performed. Criticisms include reduced working space, difficult abdominal access, and bowel injury. The experience with laparoscopic treatment of small bowel obstruction to determine its safety has been reviewed. Nineteen patients underwent laparoscopic treatment of small bowel obstruction. A cut-down technique was used for abdominal access and avoided manipulation of dilated bowel. The average number of prior operations was 1.4. The average size of maximally dilated bowel was 3.5 cm, including 6 patients whose diameter was greater than 4 cm. Laparoscopic treatment was successful in 16 patients; 3 patients required laparotomy. There were no complications from abdominal access and no iatrogenic bowel injuries. This series demonstrated that abdominal access and relief of bowel obstruction can be safely performed laparoscopically in patients with complex small bowel obstruction. Neither massively dilated bowel nor multiple previous abdominal operations precluded safe conduct of the operation laparoscopically.

Risk Factors for Bile Duct Injury During Laparoscopic Cholecystectomy: A Case-Control Study

Kholdebarin, R., Boetto, J., Harnish, J. L., Urbach, D. R. — 2008-05-20

Common bile duct injury is a serious but uncommon complication of laparoscopic cholecystectomy. A case-control epidemiologic study of patients who had undergone cholecystectomy in Ontario, Canada, between 1991 and 1997 was performed. Four patients who had undergone a laparoscopic cholecystectomy at the same hospital 2 months prior to a case were selected as controls. The risk of bile duct injury associated with various exposures was estimated by unconditional logistic regression. There were 28 cases and 88 controls. Emergency operation (adjusted odds ratio = 5.0; 95% confidence interval, 1.4-17.8) and failure to identify the cystic duct (adjusted odds ratio = 13.7; 95% confidence interval, 2.5-76.3) were statistically significant risk factors for operative bile duct injury. No other characteristics were independent risk factors for bile duct injury. Failure to identify the cystic duct and the emergency surgery are independent risk factors for bile duct injury.

Minimally Invasive Surgical Enucleation or Esophagogastrectomy for Benign Tumor of the Esophagus

Nguyen, N. T., Reavis, K. M., El-Badawi, K., Hinojosa, M. W., Smith, B. R. — 2008-05-20

Experience in surgical resection of benign tumor of the esophagus is limited. Authors performed a chart review of 5 patients who underwent minimally invasive surgical resection of benign esophageal tumor. Main outcome measures included operative approaches, tumor's location and size, and outcomes. Tumor location were middle esophagus (n = 1), distal esophagus (n = 2), and gastroesophageal junction (n = 2). There were 4 females with a mean age of 55 years. Surgical approaches included thoracoscopic enucleation (n = 1), laparoscopic enucleation (n = 1), and laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy (n = 3). There were no open conversions. Mean operative time for enucleation was 127 minutes and 240 minutes for Ivor Lewis esophagectomy. Mean hospital stay was 5.8 days. There were no major or minor complications. Three patients developed stomal stenosis. The 30-day mortality was zero. Surgical pathology showed leiomyoma in 3 patients and gastrointestinal stromal tumor in 2 patients. Tumor size ranged from 1.1 to 10.5 cm. There has been no tumor recurrence at a mean follow-up of 14 months. Minimally invasive surgical enucleation or esophagogastrectomy for benign esophageal tumor is feasible and safe. The optimal approaches should be tailored based on the location and size of the tumor.

Initial Laparoscopic Access Using an Optical Trocar Without Pneumoperitoneum Is Safe and Effective in the Morbidly Obese

Rabl, C., Palazzo, F., Aoki, H., Campos, G. M. — 2008-05-20

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m²) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.

Laparoscopic Gastric Ischemic Conditioning Prior to Esophagogastrectomy: Technique and Review

Varela, E., Reavis, K. M., Hinojosa, M. W., Nguyen, N. — 2008-05-20

Esophagectomy can be associated with significant peri-operative morbidity such as leaks and strictures. Gastric ischemia as a result of gastric devascularization is one of the several contributing factors that may play a role in development of these complications. In an attempt to improve gastric tissue perfusion, a technique of gastric ischemic conditioning was proposed. For patients with esophageal cancer and at the time of laparoscopic staging, partial gastric devascularization is achieved by division of the left gastric vessels. Esophagectomy is subsequently performed several days after the gastric ischemic conditioning procedure. Our experience showed that preoperative ligation of left gastric vessels prior to esophagogastrectomy is technically feasible and safe and may decrease ischemic complications such as leaks and strictures.

A Simple, Low-Cost Platform for Basic Laparoscopic Skills Training

Dayan, A. B., Ziv, A., Berkenstadt, H., Munz, Y. — 2008-05-20

Laparoscopic basic skills' training relies mainly on costly video trainers. The aim of this study was to evaluate a simple, low-cost devise for laparoscopic training. In all, 32 participants with varying levels of skill were recruited. A Simulab LapTrainer (Simulab, Seattle, Washington), using a simple plastic box, a webcam, and a Universal Serial Bus 2 card, was used together with standard operating tools. Participants performed 3 tasks (rope passing, peg transfer, and intracorporeal knot tying), which were video recorded and blindly assessed by 2 experts using error scores, checklists, and time. Statistical analysis included nonparametric tests and Cronbach for inter-rater reliability. A P <.05 was deemed significant. Highly significant differences were noted between groups in all tasks and for all parameters (P = .001). Inter-rater reliability was 0.88. Simulator ratings were good: 63%, excellent: 28%, and only 9% rated it as average. The Simulab LapTrainer provides a valid alternative for skills training. Its simplicity, portability, and relatively low cost make it an attractive surgical training tool.

Verbal Communication Improves Laparoscopic Team Performance

Shiliang Chang, , Waid, E., Martinec, D. V., Bin Zheng, , Swanstrom, L. L. — 2008-05-20

The impact of verbal communication on laparoscopic team performance was examined. A total of 24 dyad teams, comprisied of residents, medical students, and office staff, underwent 2 team tasks using a previously validated bench model. Twelve teams (feedback groups) received instant verbal instruction and feedback on their performance from an instructor which was compared with 12 teams (control groups) with minimal or no verbal feedback. Their performances were both video and audio taped for analysis. Surgical backgrounds were similar between feedback and control groups. Teams with more verbal feedback achieved significantly better task performance (P = .002) compared with the control group with less feedback. Impact of verbal feedback was more pronounced for tasks requiring team cooperation (aiming and navigation) than tasks depending on individual skills (knotting). Verbal communication, especially the instructions and feedback from an experienced instructor, improved team efficiency and performance.

The Selfish Mentor

Kavic, S. — 2008-05-20

An Unlikely Pioneer in Laparoscopy: Benjamin Henry Orndoff, MD

Morgenstern, L. — 2008-04-10

Novel, Web-Based, Information-Exploration Approach for Improving Operating Room Logistics and System Processes

2008-04-10

Routine clinical information systems now have the ability to gather large amounts of data that surgical managers can access to create a seamless and proactive approach to streamlining operations and minimizing delays. The challenge lies in aggregating and displaying these data in an easily accessible format that provides useful, timely information on current operations. A Web-based, graphical dashboard is described in this study, which can be used to interpret clinical operational data, allow managers to see trends in data, and help identify inefficiencies that were not apparent with more traditional, paper-based approaches. The dashboard provides a visual decision support tool that assists managers in pinpointing areas for continuous quality improvement. The limitations of paper-based techniques, the development of the automated display system, and key performance indicators in analyzing aggregate delays, time, specialties, and teamwork are reviewed. Strengths, weaknesses, opportunities, and threats associated with implementing such a program in the perioperative environment are summarized.

Association of Demographic and Treatment Variables in Long-Term Colon Cancer Survival

2008-04-10

The purpose of this study is to examine demographic and treatment variables because they relate to 5-year survival in colon cancer. The study design is analysis of 174 471 patients with colon and rectosigmoid cancer as reported to the American College of Surgeons National Cancer Data Base. Factors associated with a reduced risk of mortality included female gender (hazard ratio = 0.89; 95% confidence interval, 0.87-0.90), education status (hazard ratio = 0.87; 95% confidence interval, 0.85-0.89), increased number of lymph nodes resected (compared with <8, 8-12: hazard ratio = 0.90; 95% confidence interval, 0.89-0.92; >12: hazard ratio = 0.79; 95% confidence interval, 0.77-0.80), and addition of chemotherapy (hazard ratio = 0.69; 95% CI, 0.68-0.71). African American race (hazard ratio = 1.14; 95% confidence interval, 1.11-1.18) and increasing age correlated with an increased hazard risk (61-75 years: hazard ratio = 1.26; 95% confidence interval, 1.23-1.29; ≥76 years: hazard ratio = 2.15; 95% confidence interval, 2.09-2.21, compared with age <60 years). Survival in colon cancer is significantly impacted by patient's age, race, gender, and education status but not by income or area of residence.

Use of Laparoscopy in Evaluation and Treatment of Penetrating and Blunt Abdominal Injuries

2008-04-10

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.

Body Esteem Improves After Bariatric Surgery

Madan, A. K., Beech, B. M., Tichansky, D. S. — 2008-04-10

Body esteem is an issue for the morbidly obese. Although the primary goal of bariatric surgery is to improve, cure, and prevent medical comorbidities, the psychological aspect of bariatric surgery is just as important. Few studies have investigated the body esteem of patients after laparoscopic gastric bypass. This investigation tested the hypothesis that body esteem improves after bariatric surgery. Preoperative and postoperative patients were asked to fill out an institutional review board—exempted survey that included the Body-Esteem Scale for Adolescents and Adults (BESAA). The subscales include Appearance, Weight, and Attribution. Postoperative patients were told to fill the BESAA as they felt currently and as they felt before surgery. They felt that they had better scores currently than before surgery. Preoperative patients had worse scores than postoperative patients. As in many medical issues, body esteem improves after bariatric surgery. When discussing its benefits, psychological aspects of body esteem should be touted as well.

A High-Definition Exoscope System for Neurosurgery and Other Microsurgical Disciplines: Preliminary Report

Mamelak, A. N., Danielpour, M., Black, K. L., Hagike, M., Berci, G. — 2008-04-10

An 8-mm diameter rigid lens telescope with a focal distance of 20 cm was developed for open microsurgery. The telescope was attached to a 3-chip high-definition digital camera and then to a high-definition monitor. A pneumatic scope holder permitted repositioning. The optical quality of the device was compared with the operating microscope with a step wedge and 1-mm grid paper. Craniotomies and microsurgical dissections with the telescope system (high-definition exoscope system) were performed in a live pig model. The high-definition exoscope system provided image quality that rivaled the operating microscope even at high magnification. The system was easy to manipulate and comfortable during neurosurgical operations. The lack of stereopsis was a relative drawback of the system but was compensated for with repeated procedures. Overall, this prototype telescope-based system rivals the operating microscope optical quality and field of view. With further refinement, this system could have widespread application in many microsurgical disciplines.

Innovative Use of Quality-of-Life Data: Correlating Physiologic Parameters With Patient-Centered Symptoms-- The Example of Anemia on the Vitality of Surgical Oncology Patients

Velanovich, V. — 2008-04-10

Background: It has been difficult to correlate quality of life with physiologic parameters. This may be because of the multitude of factors that lead to a symptom. An example of a cause of fatigue, lassitude, and lack of vitality is anemia. This study explores whether a generic quality-of-life instrument's measure of vitality is correlated with anemia. Methods: Surgical oncology patients were asked to complete the SF-36. One of the domains is vitality (VT), which is a measure of fatigue (best possible score 100, worst possible score 0). Hemoglobin (Hb, gm/dL) and hematocrit (Hct, %) levels from the same period were recorded. Results: A total of 319 patients were assessed, 114 postoperative patients with no evidence of disease (NED) and 205 patients with active disease. There were no differences in Hb or Hct levels, but VT was slightly higher in NED patients. Linear regression analysis demonstrated that for overall VT, VT in patients with active malignant disease, and VT in NED patients the regression slopes were statistically significantly different from 0, although the regression coefficients (r) were all less than .5. Conclusions: There are direct correlations between Hb and Hct levels and the VT domain of the SF-36. This correlation was stronger in NED patients. The low r² values reflect that anemia is one of many factors affecting VT.

Ultrasound-Guided Breast Biopsy Curriculum for Surgical Residents

Hoover, S. J., Berry, M. P., Rossick, L., Rege, R. V., Jones, D. B. — 2008-04-10

Ultrasound-guided breast biopsy has emerged as a common method for lesion diagnosis. This study sought to instruct and measure surgical residents' performance in ultrasound-guided breast biopsy and evaluate their thoughts regarding it. Thirteen (n = 13) senior residents completed a written pretest or questionnaire and 2.5 hours of simulated breast core and vacuum needle biopsies. Residents then completed the same written exam, and their biopsy performance was rated. There was 13% overall improvement of written test scores, and 73% resident improved comfort levels with performing biopsies. Successfully performed core biopsies and vacuum biopsies were 86% and 83%, respectively. All residents reported that instruction in ultrasound-guided breast biopsy is very important and should be mandatory in residency training programs. With concentrated instruction, residents are able to learn ultrasound-guided breast biopsy with improvement in objective measures and self-confidence levels. Resident feedback was positive and emphasized the importance of this training in surgical residency curriculums.

Enhanced Robotic Surgical Training Using Augmented Visual Feedback

Judkins, T. N., Oleynikov, D., Stergiou, N. — 2008-04-10

The goal of this study was to enhance robotic surgical training via real-time augmented visual feedback. Thirty novices (medical students) were divided into 5 feedback groups (speed, relative phase, grip force, video, and control) and trained during 1 session in 3 inanimate surgical tasks with the da Vinci Surgical System. Task completion time, distance traveled, speed, curvature, relative phase, and grip force were measured immediately before and after training and during a retention test 2 weeks after training. All performance measures except relative phase improved after training and were retained after 2 weeks. Feedback-specific effects showed that the speed group was faster than other groups after training, and the grip force group applied less grip force. This study showed that the real-time augmented feedback during training can enhance the surgical performance and can potentially be beneficial for both training and surgery.

Proficiency-Based Laparoscopic Simulator Training Leads to Improved Operating Room Skill That Is Resistant to Decay

Stefanidis, D., Acker, C., Heniford, B. T. — 2008-04-10

The aim of this study was to assess skill retention in the operating room following completion of a proficiency-based laparoscopic skills curriculum. Novices (n = 15) were randomized to a control and a training group that practiced to proficiency on the Fundamentals of Laparoscopic Surgery suturing model. The performance of both groups was assessed on the simulator and on a live porcine laparoscopic Nissen fundoplication model at training completion (posttest) and 5 months later (retention test). Training to proficiency required 4.7 ±1.2 hours and 41 ± 10 repetitions. Trained participants outperformed controls, and their performance deteriorated slightly between posttests and retention tests on the simulator (505 ± 22 vs 462 ± 50, respectively; P < .05) but not in operating room (263 ± 138 vs 279 ± 88, respectively; P = .38). Proficiency-based simulator training results in durable improvement in operative skill of trainees even in the absence of practice for up to 5 months. Minute simulator performance changes do not translate to the operating room.

In-Training Sounding Board: Do the Right Thing

Kavic, S. — 2008-04-10

The First Laparoscopist in the United States: Bertram M. Bernheim, MD

Morgenstern, L. — 2008-01-04

Can We Predict Immediate Outcome After Laparoscopic Splenectomy for Splenomegaly? Multivariate Analysis of Clinical, Anatomic, and Pathologic Features After 3D Reconstruction of the Spleen

2008-01-04

The laparoscopic approach is the treatment of choice for splenectomy, but its definitive role in splenomegaly is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathological. The aim of this study was to evaluate the predictive factors on outcome after laparoscopic splenectomy in splenomegaly. We reviewed patients submitted to laparoscopic splenectomy with a final spleen weight superior to 700 g. Three-dimensional reconstruction of the spleen was performed, and spleen volume and diameters were measured. Multivariate analysis showed that factors that predicted for conversion were mediolateral diameter ( P = .039, RR: 1.43) and platelet count (P < .05, RR: 1). For intraoperative bleeding, the predictive factor was spleen volume (P < .03, RR: 1.003). Anteroposterior spleen diameter was related to operative time (P = .011), and the factor related to postoperative morbidity was age (P = .049, RR: 0.941). Local anatomy and clinical factors affect surgical outcome in laparoscopic splenectomy for splenomegaly. These factors should be taken into account when planning this kind of procedure.

Validation of the NITI Endoluminal Compression Anastomosis Ring (EndoCAR) Device and Comparison to the Traditional Circular Stapled Colorectal Anastomosis in a Porcine Model

2008-01-04

The purpose of this study was to determine whether the characteristics of compression anastomoses created by a new device are comparable to existing stapler technology. A total of 18 pigs were studied, and each served as its own control using a 27-mm compression device and a 29-mm stapler. Anastomoses were randomized to proximal and distal positions along the rectum and were separated by 10 cm. Six nonsurvival pigs were sacrificed at zero time to failure test the anastomoses. Twelve pigs were sacrificed at 14 days. Failure pressures, circumferences, and radiographic leak rates were determined. Anastomotic tissue was processed for matrix metalloproteinase, collagen, and elastin levels. The compression anastomoses had higher mean failure pressures than stapled anastomoses at zero time (103 vs 29.9 mm Hg). At 2 weeks, there was no difference between failure pressures (256 vs 250 mm Hg). During burst testing, 3 of the compression anastomoses failed at the anastomosis at 2 weeks, whereas none of the stapled anastomoses failed. The mean anastomotic circumference of the compression anastomoses was narrower than the stapled anastomoses (9.63 vs 11.25 cm, P = .001). There were no clinical leaks or radiographic leaks by barium enema at 2 weeks. There was no difference between matrix metalloproteinase, collagen, or elastin content based on tissue analysis. There were dense adhesions to 7 of 12 (58.3%) of the stapled anastomoses, whereas only 1 of 12 (8.3%) of the compression anastomoses had flimsy adhesions. A new compression anastomosis technique using a nickel-titanium alloy may be an advance in technology by reducing leaks and eliminating foreign material in the anastomosis.

Modified Robotic Lightweight Endoscope (ViKY) Validation In Vivo in a Porcine Model

Gumbs, A. A., Crovari, F., Vidal, C., Henri, P., Gayet, B. — 2008-01-04

The added precision and steadiness of a robotically held camera enables the performance of more complex procedures laparoscopically. In contrast to typical laparoscope holders, the modified lightweight robotic endoscope, the ViKY system is particularly compact, simple to set up and use, and occupies no floor space. Ease and safety of setup was confirmed in a porcine model and several common general surgical procedures were performed. The sterilizable endoscope manipulator is sufficiently small to be placed directly on the operating room table without interfering with other handheld instruments during minimally invasive surgery. The endoscope manipulator and its user interface were tested and evaluated by several surgeons during a series of 5 minimally invasive surgical training procedures in a porcine model. The endoscope manipulator described has been shown to be a practical device with performance and functionality equivalent to those of commercially available models, yet with greatly reduced size, weight, and cost.

Renal Radiosurgery: Initial Clinical Experience With Histological Evaluation

Ponsky, L. E., Mahadevan, A., Gill, I. S., Djemil, T., Novick, A. C. — 2008-01-04

The purpose of this study was to determine whether radiosurgical technology can be safely applied to renal tumors. Patients received radiosurgical treatment of renal lesions. At 8 weeks after radiosurgical treatment, patients underwent a partial or radical nephrectomy and histologic evaluation. The patients received a radiation dose of 4 Gy per fraction for 4 fractions. Patients were followed, and radiation-induced toxicities were noted. Three patients were treated for a minimum of 1 year of follow-up. All patients completed the treatments, tolerating each of the 4 fractions with no adverse events. No acute toxicities or changes in renal function were noted. None of the patients had any evidence of acute radiation injury or toxicity noted at the time of surgery or within the subsequent 12 months after the radiosurgical treatment. The last patient treated was found to have a cavity with no microscopic evidence of viable tumor after radiosurgical treatment; pathology was consistent with necrotic renal cell carcinoma, papillary type. The other 2 tumors demonstrated pathologic evidence of viable renal cell carcinoma (grade I and grade II). Tumor size remained relatively unchanged for 8 weeks after the radiosurgical treatment in all patients. The authors are extremely encouraged and cautiously optimistic with the initial results. Radiosurgery for renal tumors appears to be safe at this initial dose level.

Contraction of Gluteal Maximus Muscle on Increase of Intra-Abdominal Pressure: Role in the Fecal Continence Mechanism

Shafik, A., Olfat El Sibai, , Shafik, A. A., Shafik, I. A. — 2008-01-04

The gluteus maximus muscle (GMM) appears to contract with increased intra-abdominal pressure (IAP). The hypothesis that GMM contraction with increased IAP was investigated. The study comprised 32 healthy volunteers. IAP was measured by intravesical catheter. The response of electromyography of the GMM and external anal sphincter to sudden momentary and slow sustained straining was registered. The procedure was repeated after individual urinary bladder and GMM anesthetization. Sudden straining increased electromyographic activity of the external anal sphincter and GMM. Slow, sustained straining raised electromyographic activity of the gluteus maximus and external sphincter at differing degrees depending on straining intensity. The anesthetized gluteus maximus or urinary bladder did not respond to straining. The suggested GMM contraction on straining seems mediated through a reflex that is called "straining-gluteal reflex." This reflex appears to assist anal closure through extended and laterally rotated femur induced by gluteus contraction.

Duodenal Jejunal Bypass Sleeve: A Totally Endoscopic Device for the Treatment of Morbid Obesity

2008-01-04

Morbid obesity affects over 15 million people in the United States. Nonsurgical management produces sustained weight loss in less than 5% of patients. Despite associated comorbidities, less than 1% of obese patients seek surgical intervention. Less invasive procedures have been developed with varying success. The Endobarrier^{^TM} (GI Dynamics^{^TM}, Watertown, MA) duodenal—jejunal bypass sleeve is a totally endoscopically delivered device designed to produce weight loss in the morbidly obese. We describe the first placement of a duodenal—jejunal bypass sleeve in a patient in the United States. A blinded, randomized, prospective clinical trial was approved by the Food and Drug Administration to evaluate safety and efficacy of a novel device for weight loss in the obese. The first patient enrolled was a 36-year-old woman with body mass index of 45.2. After informed consent, endoscopic placement of the device under general anesthesia was performed using fluoroscopy to confirm positioning. The device was placed without complications. At conclusion of the 3-month study period, the device was removed endoscopically. Total weight lost by the patient was 9.09 kg. Described herein is the first deployment of the duodenal—jejunal bypass sleeve in North America. The device is delivered in a totally endoscopic manner in morbidly obese patients. In our patient, total weight loss at 3 months was 9.09 kg. Continued follow-up and enrollment is ongoing to demonstrate patient safety and efficacy. Additional studies are being performed to elucidate mechanism of weight loss and future clinical applications of this device.

NOTES Transvaginal Cholecystectomy: Report of the First Case

2008-01-04

Natural Orifice Translumenal Endoscopic Surgery is a new development area with potential advantages for patients. However, technical and ethical challenges involved in perforation and closure of a healthy organ, as seen in transgastric access, and lack of comprehension of physiopathology of these approaches haven't allowed clinical application. The present study, based on previous animal experiments, describes the first clinical application of transvaginal Natural Orifice Translumenal Endoscopic Surgery. On March 13, 2007, a 43-year-old female patient with symptomatic cholelithiasis with surgical indication was submitted to elective Natural Orifice Translumenal Endoscopic Surgery transvaginal cholecystectomy using a colonoscope, endoscopic graspers, and vaginal platform instruments. Operative time was 66 minutes, and vaginal access and closure were obtained in 15 minutes. The patient had good postoperative evolution and was dismissed within 48 hours without complications. Recent literature and experience of the present study group suggest possibilities for preliminary clinical applications by transvaginal natural orifice surgery. The access may offer earlier benefits in the literature than the transgastric route because of lack of danger of fistula and peritonitis. Further studies regarding instrument development and physiology of natural orifice surgery are ongoing, possibly bringing solutions for more advanced procedures.

Laparoscopic Diverticular Resection With Situs Inversus Totalis (SIT): Report of a Case

Jobanputra, S., Safar, B., Wexner, S. D. — 2008-01-04

Situs inversus totalis (SIT) is a rare condition where the abdominal and thoracic cavity structures are opposite of their usual position. Laparoscopic colonic surgery for this patient population is not well described, with only 2 reported cases. Our patient was a 62-year-old female with a history of SIT who underwent a laparoscopic sigmoid colectomy for recurrent diverticulitis. The procedure included the use of 4 ports. The sigmoid colon was noted on the right side. Laparoscopic resection with stapled anastomosis was performed. The patient tolerated the procedure well and was discharged home on postoperative day 5 without complications. We present a third case of laparoscopic colectomy for diverticulitis in a patient with SIT and a description of the operative procedure.

Leiomyosarcoma of the Retrohepatic Vena Cava Treated by Excision and Reconstruction With an Aortic Homograft: A Case Report and Review of Literature

2008-01-04

Leiomyosarcoma of the retrohepatic inferior vena cava is a rare entity and presents a number of diagnostic and therapeutic challenges. Here such a case is presented in which the retrohepatic inferior vena cava was excised after full mobilization of the liver under venovenous bypass. The continuity of the vena cava was restored with cryopreserved aortic homograft. The technical details with regard to total vena caval clamping, venovenous bypass, hepatic inflow occlusion, techniques of reconstruction, including the use of cryopreserved aortic homograft, and a brief review of the literature on the surgical management of retrohepatic inferior vena caval tumors are discussed.

Optimizing the MIS Fellowship Experience

Sherman, V., Kavic, S. — 2008-01-04

Surgeons are committed to the principle of improving clinical practice through assessment of personal outcomes. Indeed, "practice-based learning and improvement" has been adopted as one of the 6 core competencies that are required areas of instruction and evaluation in surgical residency. Residents are encouraged to analyze their own experiences, ideally in a systematic fashion, in the hopes that this semi-objective process will lead to better patient care.

At what point does this reflective process begin, and how do we teach it? In our students, it is too early—there is an obvious need to experience surgical clerkships before it is possible to appraise their experience. For residents and fellows, it is worthwhile to hear about the process from those who have had the opportunity to reflect and are still close enough to training to speak the common tongue.

In this issue, Dr. Vadim Sherman examines some of the evolution of his thoughts on surgical training. As he has transitioned from medical student to resident, resident to fellow, fellow to attending, and attending to fellowship director, he has a unique vantage point to discuss training in minimally invasive surgery. I hope that you enjoy his commentary, and I look forward to your responses and reactions to this column.

Book Review: Pasic RP, Levine RL (editors). A Practical Manual of Laparoscopy and Minimally Invasive Gynecology: A Clinical Cookbook, 2nd ed. London: Informa Healthcare; 2007. (454 pp, $180.00)

Schwaitzberg, S. — 2008-01-04

Endoscopist and Artist: Chevalier Jackson, MD

Morgenstern, L. — 2007-10-10

Methodological Infrastructure in Surgical Ergonomics: A Review of Tasks, Models, and Measurement Systems

Lee, G., Lee, T., Dexter, D., Klein, R., Park, A. — 2007-10-10

Though in its infancy, the discipline of surgical ergonomics is increasingly valued. Still, little has been written regarding this field's tasks, models, and measurement systems. These 3 critical experimental components are crucial in objectively and accurately assessing joint and postural control as exhibited by expert laparoscopic surgeons. Such assessments will establish characteristic patterns important for surgical training. In addition, risk factors associated with both minimally invasive surgical instruments and the operating room environment can be identified and minimized. Our review focuses on evidence-based experimental ergonomic studies undertaken in the field of laparoscopic surgery. Publications were located through PubMed and other database and library searches. This article describes tasks, models, and measurement systems and considers their specific applications and the types of data obtainable with the use of each. Advantages and limitations, especially those of measurement systems, are compared and discussed. Future trends and directions believed necessary for optimal investigation and results are also addressed.

Characterization of Heavyweight and Lightweight Polypropylene Prosthetic Mesh Explants From a Single Patient

2007-10-10

Although polypropylene has been used as a hernia repair material for nearly 50 years, very little science has been applied to studying the body's effect on this material. It is possible that oxidation of mesh occurs as a result of the chemical structure of polypropylene and the physiological conditions to which it is subjected; this leads to embrittlement of the material, impaired abdominal movement, and chronic pain. It is also possible that lightweight polypropylene meshes undergo less oxidation due to a reduced inflammatory reaction. The objective of this study was to characterize explanted hernia meshes using techniques such as scanning electron microscopy, differential scanning calorimetry, thermogravimetric analysis, and compliance testing to determine whether the mesh density of polypropylene affects the oxidative degradation of the material. The hypothesis was that heavyweight polypropylene would incite a more intense inflammatory response than lightweight polypropylene and thus undergo greater oxidative degradation. Overall, the results support this theory.

Laparoscopic Heller Myotomy for Achalasia in 101 Patients: Can Successful Symptomatic Outcomes Be Predicted?

Rosen, M. J., Novitsky, Y. W., Cobb, W. S., Kercher, K. W., Todd Heniford, B. — 2007-10-10

We aimed to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy for achalasia and identify the factors that might predict postoperative dysphagia or symptomatic reflux. A retrospective analysis of all patients undergoing laparoscopic Heller myotomy from January 1997 to June 2004 was performed. Postoperative frequency and severity of reflux, dysphagia, chest pain, and regurgitation were evaluated using a standardized telephone interview. Forty-eight males and 53 females, with an average age of 45 years, underwent laparoscopic Heller myotomy during the study period. Prior to presentation, 65% of patients had undergone pneumatic dilatation (52%) and/or Botox injection (28%). The mean lower esophageal sphincter pressure was 44 mmHg. A Toupet fundoplication was performed in 89 patients, and 12 patients had no fundoplication. There were no intraoperative complications and 10 minor postoperative complications. During an average follow-up of 34 months (range 2-90), 15% of patients had a weekly dysphagia, and 16% had subjective reflux. Only an older age predicted higher incidence of postoperative dysphagia. No factors were identified to predict postoperative symptomatic reflux. Eighty-one percent of patients rated their outcome as excellent, 14% good, 4% fair, and 1% poor. Ninety-nine percent of patients would choose surgery over other treatment options again. Laparoscopic anterior esophageal myotomy is a safe and effective treatment for achalasia. Improvement in dysphagia can be expected in more than 95% of patients. Younger patients tended to have better improvement of dysphagia. Predicting the patients at higher risk for postoperative reflux remains elusive at this time.

Telementoring for Minimally Invasive Surgical Training by Wireless Robot

Sereno, S., Mutter, D., Dallemagne, B., Smith, C.D., Marescaux, J. — 2007-10-10

Hands-on training courses with local mentoring are excellent educational tools in laparoscopic surgery; however, the need for the physical presence of specialized instructors represents a limitation because of costs, time, and geographic constraints. Remote robotic telementoring using a wireless videoconferencing mobile robot could represent an alternative to local instruction. The authors compare local active and passive mentoring with remote robotic telementoring using the wireless RP-6 Robot that worked through a WiFi 802.11b connection during a hands-on laparoscopic training session. Surgeons were mentored once in France from the United States. Robot mentoring was well received and appreciated (assessment score of 2.65; scale, 0 to 4). There was no statistical difference in the different mentoring sessions (active, passive, and remote). Mobile wireless robot is a valuable tool in laparoscopic telementoring. Robotic-assisted telementoring may not replace onsite mentoring, but it may enhance educational opportunities and the quality of hands-on training courses by implementing tutoring with expert assistance from remote locations.

Misclassification of Hospital Volume With Surveillance, Epidemiology, and End Results Medicare Data

Hollenbeck, B. K., Hong Ji, , Zaojun Ye, , Birkmeyer, J. D. — 2007-10-10

Surveillance, Epidemiology, and End Results (SEER)— Medicare data are frequently used for studying relationships between volume and outcomes after cancer surgery; however, because patients often cross SEER boundaries for treatment, SEER-Medicare data may misclassify hospital volume. Thus, we measured the agreement of hospital volume as determined by SEER-Medicare and 100% national Medicare data and determined the extent to which misclassification alters the apparent relationship between volume and operative mortality. This is a retrospective cohort study of SEER-Medicare patients undergoing a major cancer surgery for colon, lung, bladder, and esophageal cancers between 1994 and 1999. Hospital procedure volumes were assessed with both SEER-Medicare and 100% national Medicare data and sorted into terciles. Logistic regression models were fit using generalized estimating equations to assess associations between mortality and volume, as determined from each data source. Compared with 100% Medicare data, SEER-Medicare data misclassified 13% (colectomy) to 36% (esophagectomy) of patients; however, fewer than 3% of patients were misclassified by more than 1 volume stratum. For cystectomy, the apparent association between volume and mortality was relatively weak and not statistically significant based on SEER-Medicare data (adjusted odds ratio, low vs high volume 1.41, 95% confidence interval, 0.89-2.23), but stronger and significant when volume was obtained from 100% Medicare data (odds ratio, 1.82; 95% confidence interval, 1.17 to 2.84). For the other 3 procedures, apparent volume/outcome relationships were similar when volume was assessed from the 2 data sources. Hospital volumes are frequently misclassified with SEER-Medicare data. Such misclassification generally biases volume/outcome associations toward the null, but this effect seems to be small for many procedures. Investigators should be cognizant of this bias and exercise caution when interpreting these relationships when using SEER-Medicare data alone.

Parastomal Hernia: Short-Term Outcome After Laparoscopic and Conventional Repairs

2007-10-10

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 ± 58 vs 162 ± 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P ≤ .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.

Broad-Based Fellowships: A Cornerstone of Minimally Invasive Surgery Education and Dissemination

2007-10-10

Aware of the trends in surgery and of public demand, many residents completing a 5-year training program seek fellowships in minimally invasive surgery (MIS) because of inadequate exposure to advanced MIS during their residency. A survey was designed to evaluate the effectiveness of a broad-based fellowship in advanced laparoscopic surgery offered in an academic health science center. The questionnaire was mailed to all graduates. Data on demographics, comfort level with specific laparoscopic procedures, and opinions regarding the best methods of acquiring these skills were collected. Most of the surgeons entered the fellowship directly after residency. The majority of these surgeons are academic surgeons. Fellows performed a median of 187 cases by the end of their training and felt comfortable operating on foregut, hindgut, and end organ. A full year of training was found to be the best format for appropriate skill transfer. A broad-based MIS fellowship meets the needs of both academic and community surgeons desiring to perform advanced laparoscopic procedures.

Evaluating Intraoperative Laparoscopic Skill: Direct Observation Versus Blinded Videotaped Performances

2007-10-10

The Global Operative Assessment of Laparoscopic Skill (GOALS) has been shown to meet high standards for direct observation. The purpose of this study was to investigate the reliability and validity of GOALS when applied to blinded, videotaped performances. Five novice surgeons and 5 experienced surgeons were each evaluated by 2 observers during a laparoscopic cholecystectomy. Subsequently, 4 laparoscopists (V1 to V4) evaluated the videotaped procedures using GOALS. Two of the raters (V1 and V3) had prior experience using GOALS. The interrater reliabilities between video raters (VRs) and between VRs and direct raters (DRs) were calculated using the intraclass correlation coefficient. Construct validity was assessed using 2-way analysis of variance. Interrater reliability between the 4 VRs and the 2 DRs was 0.72. The intraclass correlation coefficient for the 4 VRs was 0.68 and for each VR compared with the mean DR was 0.86, 0.39, 0.94, and 0.76, respectively. All raters, except V2, differentiated between novice and experienced groups (P values ranged from .01 to .05). These data suggest that GOALS can be used to assess laparoscopic skill based on videotaped performances but that rater training may play an important role in ensuring the reliability and validity of the instrument. Experience with the tool in the operating room may improve the reliability of video rating and could be of value in training evaluators.

Innovative Dynamic Minimally Invasive Training Environment (DynaMITE)

2007-10-10

Existing laparoscopic box trainers consist only of static tasks and do not adequately prepare surgeons to navigate the dynamic surgical environment. This paper describes an innovative design using controlled motorized target movements to enhance the training of dynamic motor skills. The prototype was tested using 15 subjects with different surgical experience levels. The task required accurate contact, using a laparoscopic tool, with targets moving in 5 different movement trajectories: (1) static, (2) horizontal, (3) vertical, (4) slow hourglass-shaped, and (5) fast hourglass-shaped. Expert surgeons were significantly faster than novices in the static, horizontal, and slow hourglass target conditions. Intermediate experienced subjects (PGY2s) were faster than novices in the horizontal target condition only. In the fast hourglass condition, experts were not faster than less experienced and novice subjects, but they were more accurate. There is the potential to train hand-eye coordination of even expert surgeons using this dynamic environment.

Laparoscopic Revision of Gastrogastric Stricture With a Transoral Circular Stapler

Parikh, M., Gagner, M. — 2007-10-10

Most anastomotic strictures can be effectively managed by endoscopic dilations. Patients with severe strictures refractory to balloon dilations may require surgical revision. Revision of a strictured anastomosis (open or laparoscopic) is often technically demanding because of the severity of adhesion formation and difficulty in correctly identifying the anatomy. We discuss a laparoscopic method of safely revising an anastomotic stricture with a circular stapler.

The Transition to Mona

Roberts, P., Brown, H. — 2007-10-10