Is the robotic revolution stunting surgical skills?

This perspective piece aims to examine the impact of the growing utilization of robotic platforms in general and minimally invasive surgery on surgical trainee experience, skill level, and comfort in performing general surgical and minimally invasive procedures following completion of training. We review current literature and explore the application of robotic surgery to surgical training, where minimum case thresholds and breadth distribution are well defined, and where development of surgical technique is historically gained through delicate tissue handling with haptic feedback rather than relying on visual feedback alone. We call for careful consideration as to how best to incorporate robotics in surgical training in order to embrace technological advances without endangering the surgical proficiency of the surgeons of tomorrow. Key message: The large-scale incorporation of robotics into general and minimally invasive surgical training is something that most, if not all, trainees must grapple with in today's world, and the proportion of robotics is increasing. This shift may significantly negatively affect trainees in terms of surgical skill upon completion of training and must be approached with an appropriate degree of concern and thoughtfulness so as to protect the surgeons of tomorrow.

The response of early neural genes to FGF signaling or inhibition of BMP indicate the absence of a conserved neural induction module.

BACKGROUND: The molecular mechanism that initiates the formation of the vertebrate central nervous system has long been debated. Studies in Xenopus and mouse demonstrate that inhibition of BMP signaling is sufficient to induce neural tissue in explants or ES cells respectively, whereas studies in chick argue that instructive FGF signaling is also required for the expression of neural genes. Although additional signals may be involved in neural induction and patterning, here we focus on the roles of BMP inhibition and FGF8a. RESULTS: To address the question of necessity and sufficiency of BMP inhibition and FGF signaling, we compared the temporal expression of the five earliest genes expressed in the neuroectoderm and determined their requirements for induction at the onset of neural plate formation in Xenopus. Our results demonstrate that the onset and peak of expression of the genes vary and that they have different regulatory requirements and are therefore unlikely to share a conserved neural induction regulatory module. Even though all require inhibition of BMP for expression, some also require FGF signaling; expression of the early-onset pan-neural genes sox2 and foxd5α requires FGF signaling while other early genes, sox3, geminin and zicr1 are induced by BMP inhibition alone. CONCLUSIONS: We demonstrate that BMP inhibition and FGF signaling induce neural genes independently of each other. Together our data indicate that although the spatiotemporal expression patterns of early neural genes are similar, the mechanisms involved in their expression are distinct and there are different signaling requirements for the expression of each gene.

The role of the assistant in laparoscopic surgery: important considerations for the apprentice-in-training.

Laparoscopic surgery is a dynamic and integral component of surgical training. In many surgical programs, the surgeon-in-training gradually incorporates the knowledge and skill-sets through a variable spectrum of assistant/ apprentice instruction with different surgical mentors. As a result, this lack of formal and/or standardized instruction may be inconsistent with a structured educational process. In the year 2008, with widespread applications for minimally invasive techniques and technology, contributions from skilled assistants are now increasingly more important for effective and safe operative conduct. Incorporating these challenges into a balanced educational process remains no easy matter. The authors believe the assistant's role is vital to all aspects of laparoscopic surgery, no matter how routine or complex. Laparoscopic assistants should participate and contribute directly in the (a) preoperative evaluation and preparation, (b) patient positioning, (c) operative suite arrangement, (d) trocar placement, plus important (e) intraoperative maneuvers contingent upon acquired mastery of laparoscopic skills. Understanding these principles plus effective administration of various duties allows for the apprentice in training to progress to more complex procedures and eventual primary surgeon responsibility. In this report, the role of the laparoscopic assistant/apprentice is reviewed, with particular attention focused on requisite fundamentals for evolving laparoscopic surgeons. To date, there are few publications within the world literature that directly address these observations. Important considerations delineating the expectations and goals for the assistant/apprentice, as well as the mentor, during laparoscopic training are provided.

Ante-hepatic gastrojejunostomy.

Surgical treatment of morbid obesity continues to increase in popularity. The evolution of laparoscopic techniques has in part fueled that popularity. A common obstacle in achieving exposure of the angle of His during a laparoscopic Roux-en-Y gastric bypass is a massively enlarged liver. Exposure of the angle of His is key to successfully creating the gastric pouch and completing the gastrojejunostomy. Several well-described techniques exist to achieve this exposure but suffer from potential draw backs such as bleeding and the need to insert additional trocars. We describe a technique that allows safe, excellent exposure of the gastroesophageal junction during laparoscopic Roux-en-Y gastric bypass.

Postherniorrhaphy groin pain and how to avoid it.

Groin pain following inguinal hernia repair remains a challenge to most general surgeons. Prevention of groin pain may be the most effective solution to this management problem and necessitates careful anatomic dissection and precise knowledge of surgical anatomy of the groin as well as potential pitfalls of surgical intervention. When complications arise, a period of watchful waiting is warranted, but surgical intervention with triple neurectomy offers the most definitive resolution of symptoms. This article aims to provide a thorough review of pertinent anatomic landmarks for the proper identification of the nerves that, if injured, result in chronic groin pain and to provide a treatment algorithm for patients suffering with this morbidity.

Invasive amebiasis and ameboma formation presenting as a rectal mass: An uncommon case of malignant masquerade at a western medical center.

A 54-year-old man presented with rectal pain and bleeding secondary to ulcerated, necrotic rectal and cecal masses that resembled colorectal carcinoma upon colonoscopy. These masses were later determined to be benign amebomas caused by invasive Entamoeba histolytica, which regressed completely with medical therapy. In Western countries, the occurrence of invasive protozoan infection with formation of amebomas is very rare and can mistakenly masquerade as a neoplasm. Not surprisingly, there have been very few cases reported of this clinical entity within the United States. Moreover, we report a patient that had an extremely rare occurrence of two synchronous lesions, one involving the rectum and the other situated in the cecum. We review the current literature on the pathogenesis of invasive E. histolytica infection and ameboma formation, as well as management of this rare disease entity at a western medical center.

Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis.

HYPOTHESIS: Outcome following laparoscopic adjustable gastric banding (LAGB) in super morbidly obese patients is significantly worse compared with the standard laparoscopic Roux-en-Y gastric bypass (LRYGB). DESIGN: Prospective case series. SETTING: Community teaching hospital (490 beds). PATIENTS: A prospectively maintained database identified patients who underwent operative treatment for morbid obesity between February 2001 and June 2004. The study group included super morbidly obese patients (body mass index >50 [calculated as weight in kilograms divided by the square of height in meters]) following LAGB and LRYGB. INTERVENTIONS: Among 106 patients with super morbid obesity, 60 (57%) and 46 (43%) underwent LAGB and LRYGB, respectively. MAIN OUTCOME MEASURES: Patient demographics, weight loss, percentage of excess weight loss, change in body mass index, early (<30 days) and late (> or =30 days) complications, reoperations, medical comorbidity, and patient satisfaction were studied. Analysis was performed using the t test and Pearson chi 2 analysis. RESULTS: Overall median follow-up was 16.2 months (range, 1-40 months). Preoperative factors of patient age, sex, weight, body mass index, and medical comorbidity were similar between the 2 groups. Compared with LRYGB, patients who underwent LAGB experienced a greater incidence of late complications (P < .05), reoperations (P < .04), less weight loss (P<.001), and decreased overall satisfaction (P < .006). Likewise, patients who underwent LRYGB had a greater resolution of concomitant diabetes mellitus (P < .05) and sleep apnea (P<.01) compared with the LAGB group. Furthermore, postoperative adjustments to achieve consistent weight loss for LAGB recipients ranged from 1 to 15 manipulations. Our single mortality was in the LAGB group. CONCLUSIONS: In super morbidly obese patients, LAGB is significantly associated with more late complications, reoperations, less weight loss, less reduction of medical comorbidity, and patient dissatisfaction compared with LRYGB. Further evaluation of LAGB in this patient population appears warranted.

Mesh infection in the era of laparoscopy.

BACKGROUND: The incidence of mesh infection during open hernia repair has been reported to be as high as 3%. With the introduction of laparoscopy, the rate of infection is still a matter of debate. METHODS: All 1182 laparoscopic inguinal hernia repairs performed at our institution from September 1991 to June 2002 were retrospectively reviewed to identify both mesh and wound infections. RESULTS: There were two mesh infections (0.17%) during that period, and one wound infection. CONCLUSION: The incidence of mesh infection in laparoscopic repair is considerably lower than in the open procedure. The two main reasons for this are the introduction of mesh through trocars to avoid skin contact, and the mesh is placed far from the trocar incisions, again avoiding contamination. The rate of wound infection is not related to that of mesh infection, and depends mainly on aseptic prepping techniques prior to surgery.

Intracorporeal suturing and knot tying broadens the clinical applicability of laparoscopy.

OBJECTIVE: As surgeons become more experienced with basic laparoscopic procedures like cholecystectomy, they are able to expand this approach to less common operations. However, without laparoscopic suturing skills, like those obtained with Nissen fundoplication, many operations cannot be completed laparoscopically. We present a series of 10 patients with less common surgical illnesses who were successfully treated with minimal access techniques and intracorporeal suturing. METHODS: Over a 6-month period at 2 medical centers, 10 patients underwent operations with laparoscopic intracorporeal suturing and knot tying. Diagnoses included bowel obstruction due to gallstone ileus (n=1), perforated uterus from an intrauterine device (n=1), urinary bladder diverticulum (n=1), bleeding Meckel's diverticulum (n=3), and perforated duodenal ulcer (n=4). RESULTS: Each patient was treated with standard surgical interventions performed entirely laparoscopically with intracorporeal suturing. No morbidity or mortality occurred in any patient due to the operation. CONCLUSIONS: Although each of these operations has been previously reported, as a series, they point out the importance of mastering laparoscopic suturing. Although devices are commercially available to facilitate certain suturing scenarios, we encourage residents and fellows to sew manually. We believe that none of these operations could have been completed as effectively by using a suture device. The ability to suture laparoscopically markedly broadens the number of clinical scenarios in which minimal access techniques can be used.

Breast Biopsies with ABBI(R): Experience with 183 Attempted Biopsies.

When first introduced, the advanced breast biopsy instrumentation (ABBI(R)) system seemed to have many advantages as a diagnostic procedure. Problems have arisen, however, both in terms of patient unsuitability and mechanical failure. In addition, there has been uncertainty as to whether the complete lesion removal it afforded could be considered definitive treatment in malignant cases. Incision margins were looked at to investigate that possibility. Of the 183 patients we saw in our first year of experience with ABBI, 48 (26%) were rejected for being poor candidates for it. In the remaining 132 biopsies there were 31 (23%) technical difficulties. All told, 14 malignancies were discovered, all of which appeared to have pathology-free incision margins radiologically. However, 13 of these 14 (93%) proved on pathologic examination to have residual malignancy.