Impact of continuous training through distributed practice for acquisition of minimally invasive surgical skills.

BACKGROUND: Minimally invasive surgery (MIS) requires the mastery of manual skills and a specific training is required. Apart from residencies and fellowships in MIS, other learning opportunities utilize massive training, mainly with use of simulators in short courses. A long-term postgraduate course represents an opportunity to learn through training using distributed practice. OBJECTIVE: The objective of this study is to assess the use of distributed practice for acquisition of basic minimally invasive skills in surgeons who participated in a long-term MIS postgraduate course. METHODS: A prospective, longitudinal and quantitative study was conducted among surgeons who attended a 1-year postgraduate course of MIS in Brazil, from 2012 to 2014. They were tested through five different exercises in box trainers (peg-transfer, passing, cutting, intracorporeal knot, and suture) in the first (t0), fourth (t1) and last, eighth, (t2) meetings of this course. The time and penalties of each exercise were collected for each participant. Participant skills were assessed based on time and accuracy on a previously tested score. RESULTS: Fifty-seven surgeons (participants) from three consecutive groups participated in this study. There was a significant improvement in scores in all exercises. The average increase in scores between t0 and t2 was 88% for peg-transfer, 174% for passing, 149% for cutting, 130% for intracorporeal knot, and 120% for suture (p < 0.001 for all exercises). CONCLUSION: Learning through distributed practice is effective and should be integrated into a MIS postgraduate course curriculum for acquisition of core skills.

Retention of laparoscopic skills in naive medical students who underwent short training.

BACKGROUND: Simulators are useful tools in the development of laparoscopic skills. However, little is known about the effectiveness of short laparoscopic training sessions and how retention of skills occurs in surgical trainees who are naïve to laparoscopy. This study analyses the retention of laparoscopic surgical skills in medical students without prior surgical training. METHODS: A group of first- and second-year medical students (n = 68), without prior experience in surgery or laparoscopy, answered a demographic questionnaire and had their laparoscopic skills assessed by the Fundamentals of Laparoscopic Surgery (FLS) training protocol. Subsequently, they underwent a 150-minute training course after which they were re-tested. One year after the training, the medical students' performance in the simulator was re-evaluated in order to analyse retention. RESULTS: Of the initial 68 students, a total of 36 participated throughout the entire study, giving a final participation rate of 52 %. Thirty-six medical students with no gender predominance and an average age of 20 years were evaluated. One year after the short training programme, retention was 69.3 % in the peg transfer (p < 0.05) and 64.2 % in ligature (p < 0.05) compared with immediate post-training evaluation. There was no significant difference in suturing. The average sample score in the baseline test was 8.3, in the post-training test it was 89.7, and in the retention test it was 84.2, which corresponded to a skill retention equivalence of 93 %. CONCLUSIONS: There was a significant retention of the laparoscopic surgical skills developed. Even 1 year after a short training session, medical students without previous surgical experience showed that they have retained a great part of the skills acquired through training.

Omentum patch substitute for facilitating endoscopic repair of GI perforations: an early laparoscopic pilot study with a foam matrix plug (with video).

BACKGROUND: Endoscopic perforations are surgically repaired by using an omentum patch. Omentum substitutes may have broader applications particularly in certain sites (eg, esophagus). OBJECTIVE: Evaluate a self-expandable foam matrix plug as a synthetic omentum substitute for repairing iatrogenic gastric perforations in a 4-week survival pig model. DESIGN: Experimental pilot study. SETTING: Laboratory. INTERVENTION: A laparoscopic plug repair of a 1-cm, full-thickness, gastric perforation was carried out by using either a polyurethane foam matrix plug (FMP, 8 animals) or an omentum plug (OP, 6 animals, control group). MAIN OUTCOME MEASUREMENTS: Follow-up endoscopy was carried out at 1 and 4 weeks. At necropsy, the perforation site was evaluated for adhesions and histology by using hematoxylin and eosin analysis. A portion of the implant was sent for bacterial and fungal culture. RESULTS: All procedures were technically simple and successful. Thirteen animals thrived well for 4 weeks. One animal from the FMP group died 3 days postoperatively from diffuse peritonitis because of a misplaced plug. All remaining FMPs were intact at 4 weeks and colonized with mixed bacteria, except one animal presenting with FMP migration after 1 week. Histologically, the FMP group had more prominent inflammation and suppuration as compared with the OP group, all limited to its adjacent tissue. LIMITATIONS: Animal study. CONCLUSION: The FMP offered a technically simple and feasible option for repairing iatrogenic gastric perforations. With effective sealing, the clinical outcome is similar to that of an omentum patch repair. Migration and inadequate sealing is a concern, which can lead to peritonitis and sepsis. Further development is needed to improve FMP performance.

A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique.

BACKGROUND: Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM and analyze the outcomes of each method after a 4 week survival period. METHODS: Twenty-four pigs were randomly assigned into group A (FTM, 12 animals) and group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2 weeks, and after 4 weeks between groups A and B. The P value was set as <0.05 for significance. RESULTS: Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (nine animals each) at baseline [group A = 23 (10.4) mmHg; group B = 20.7 (8.7) mmHg; P = 0.79], after 2 weeks [group A = 19 (7.7) mmHg; group B = 21.8 (8.4) mmHg; P = 0.79], and after 4 weeks [group A = 22.6 (10.2) mmHg; group B = 20.7 (9) mmHg; P = 0.82]. LES pressures were significantly reduced in three animals after 4 weeks: one animal (1%) in group A and two animals (2.5%) in group B. An extended myotomy (3 cm below the cardia) was achieved in three animals and was responsible for the significant drop in LES pressure seen in the two animals from group B. CONCLUSION: Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia.

Laparoscopic ultrasound-assisted liposuction for lymph node dissection: a pilot study.

BACKGROUND: Lymphadenectomy is a surgical technique for staging and treating cancer. Laparoscopic lymphadenectomy for obese patients is challenging. Laparoscopic ultrasound-assisted liposuction (UAL) has been successful in porcine models. The current study aimed to evaluate whether UAL facilitates pelvic laparoscopic lymphadenectomy in obese subjects. METHODS: The UAL technique was evaluated in two human cadavers and in six obese Ossabaw pigs. Both a standard and a prototype ultrasonic probe with a wider contact surface were tested. Pelvic lymphadenectomy comparing UAL with standard monopolar cautery was performed using obese Ossabaw pigs. The animals were survived for 2 weeks. Descriptive data regarding intra- and postoperative outcomes were recorded, including histologic analysis of dissected tissue after 2 weeks. Cytologic analysis of aspirated fluid coming from UAL also was recorded. RESULTS: The UAL procedure was safely performed for all the cadavers and animals. Lymph node exposure and clean exposure of surrounding structures were dramatic compared with monopolar assisted dissection. One animal was excluded from further analysis due to ultrasonic device malfunction (a broken footswitch cord). In general, UAL notably debulks adipose tissue with dramatic field exposure. Postoperative adhesions were present in all animals undergoing either monopolar or UAL dissection. Histology showed areas of foreign body reaction from mild to severe, with no predominance of either extreme seen with monopolar or UAL dissection. Cytologic analysis of collected pooled oil emulsion did not contain lymph node tissue. CONCLUSION: The UAL approach permits pelvic lymphadenectomy in the obese animal and cadaver model, with excellent exposure of lymph nodes and surrounding pelvic anatomy. The use of a new ultrasonic prototype probe with a wider contact surface allowed dissection with less mechanical and thermal penetration of tissue. Further studies are needed to assess oncologic safety (cancer cell dissemination), postoperative healing, and adhesion formation.

Natural orifice transluminal endoscopic surgery for patients with perforated peptic ulcer.

BACKGROUND: Perforation accounts for 70% of deaths attributed to peptic ulcers. Laparoscopic repair is effective but infrequently used. Our aim was to assess how many patients with perforated peptic ulcer could be candidates for a transluminal endoscopic omental patch closure. METHODS: This retrospective study reviewed patients with perforated peptic ulcer from 2005 to 2010. Demographics, ulcer characteristics, operative procedure, and outcomes were recorded. Candidates for endoscopic transluminal repair were defined as those having undergone omental patch closure of an ulcer of appropriate size and no contraindications to laparoscopy or endoscopy. RESULTS: In the retrospective review, a total of 104 patients were identified; 62% female, mean age = 68 years, mean ASA of 3, and 63% medication-related ulcers. Fifty-nine (63%) had an omental patch (80% open), and 35 (37%) had other procedures. Ten patients had nonoperative management. Thirty-day mortality was 14% and 1 year mortality was 35%. Forty-nine patients (52%) were considered potential candidates for transluminal repair. CONCLUSION: Sixty-three percent of our patients sustained a medication-related perforation with 1 year mortality of 35%. The majority of patients were treated using open omental patch repair. Transluminal endoscopic repair may provide an additional situation for a minimally invasive approach for a number of these patients.

Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches.

INTRODUCTION: Endoscopic surgical repair of inguinal hernia is currently conducted using 2 techniques: the totally extraperitoneal (TEP) and the transabdominal (TAPP) hernia repair. The TEP procedure is technically advantageous, because of the use of no mesh fixation and the elimination of the peritoneal flap, leading to less postoperative pain and faster recovery. The drawback is that TEP is not performed as frequently, because of its complexity and longer learning curve. In this study, we propose a hybrid technique that could potentially become the gold standard of minimally invasive inguinal hernia surgery. This will be achieved by combining established advantages of TEP and TAPP associated with the precision and cosmetics of minilaparoscopy (MINI). MATERIALS AND SURGICAL TECHNIQUE: Between January and July 2011, 22 patients were admitted for endoscopic inguinal hernia repair. The combined technique was initiated with TAPP inspection and direct visualization of a minilaparoscopic trocar dissection of the preperitoneum space. A10-mm trocar was then placed inside the previously dissected preperitoneal space, using the same umbilical TAPP skin incision. Minilaparoscopic retroperitoneal dissection was completed by TEP, and the surgical procedure was finalized with intraperitoneal review and correction of the preperitoneal work. DISCUSSION: The minilaparoscopic TEP-TAPP combined approach for inguinal hernia is feasible, safe, and allows a simple endoscopic repair. This is achieved by combining features and advantages of both TAPP and TEP techniques using precise and sophisticated MINI instruments. Minilaparoscopic preperitoneal dissection allows a faster and easier creation of the preperitoneal space for the TEP component of the procedure.

Preoperative biliary stents in pancreatic cancer.

BACKGROUND: Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated. METHODS: A review of the literature using Medline, Embase and Cochrane databases was undertaken. RESULTS: Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed. CONCLUSION: Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.

Update on the indications and use of colonic stents.

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Vólvulo da vesícula biliar tratado por colecistectomia laparoscópica / Volvulus of the gallbladder treated by laparoscopic cholecystectomy

Our objective is to report a case of gallbladder torsion treated by laparoscopic cholecystectomy. A 87 year old patient presented with intense right upper quadrant pain, anorexia, nausea and vomiting. Murphy's sign was present at physical examination. Hemogram showed 9.200 leukocytes/mm3, with six bands. Ultrassonography showed a distended gallbladder, perivesicular fluid collection, wall edema, and sludge with stones inside. At laparoscopic cholecystectomy, there was a complete gallbladder torsion with areas of necrosis. There was no postoperative complication. Pathologic examination confirmed the diagnosis of acute calculous cholecystitis with areas of necrosis