Laparoscopic Revision of Failed Bariatric Procedures.

BACKGROUND: The main indications for revision of bariatric surgery are inadequate weight loss, weight regain, or complications. The objective of revision is to restore the restrictive component and/or add a malabsorptive component. OBJECTIVES: To evaluate the effectiveness of revisional laparoscopic bariatric surgery for loss of weight and assess the risks and benefits associated with these technically demanding procedures. METHODS: Revision cases performed between 2001 and 2013 were identified and grouped according to the primary procedure and type of revision. A retrospective analysis was carried out for weight loss as well as perioperative morbidity and mortality. RESULTS: The total of 271 patients underwent revisional laparoscopic surgery during the study period and were categorized into four groups. Group 1 (n = 67) had an adjustable gastric band converted to gastric bypass (GBP). Group 2 (n = 128) had a dilated gastric pouch after GBP and underwent pouch reduction. Group 3 (n = 57) had a GBP and underwent pouch reduction and elongation of the biliopancreatic limb. Group 4 (n = 19) had a vertical banded gastroplasty converted to a GBP. The mean total body weight loss for Groups 1 to 4 was 35.3%, 22.9%, 39.4%, and 33.2%, respectively. The average operative times were 185, 75, 142, and 205 minutes; and the average hospitalization was 1.5, 1.0, 2.0, and 2.5 days, respectively. All cases were completed laparoscopically. Concomitant procedures were liver biopsy, cholecystectomy, partial gastrectomy, hiatal, ventral, and internal hernia repairs. Complication rates were 2.9%, 0%, 3.5%, and 5.2% for each of the groups and there were no mortalities. CONCLUSION: Results of revisional bariatric surgery vary depending on the original procedure and the reasons for revision. In particular, if the main reason for reoperation is inadequate weight loss, then the burden is to demonstrate a surgically correctable deficiency. Revisional procedures incorporating malabsorption result in greater weight loss than gastric restriction alone.

Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett's esophagus.

BACKGROUND: We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR). METHODS: Patient demographics, operative outcomes, and follow-up results were tabulated. RESULTS: LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett's epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae. CONCLUSIONS: LTEMR is safe and effective alternative method to treat patients with Barrett's esophagus with high-grade dysplasia.

Routine anticoagulation for venous thromboembolism prevention following laparoscopic gastric bypass.

OBJECTIVE: To compare the rates of venous thromboembolism (VTE) by using routine postoperative enoxaparin versus early ambulation, SCDs, hydration, and selective prophylactic pharmacologic anticoagulation. METHODS: 1,692 patients undergoing laparoscopic gastric bypass from October 2001 to October 2008 were included and divided into 2 groups based on when they were operated upon. Group A (435 patients) received routine enoxaparin 12 hours after surgery. Group B (1,257 patients) received selective pharmacologic anticoagulation, in high-risk patients only. RESULTS: Mean operating time was 144±26 minutes (Group A) and 126±15 minutes (Group B). Mean length of stay was 2.3±1.5 days for Group A and 1.4±1.2 for Group B. Intraluminal bleeding occurred in 21 patients (4.8%) in Group A and 5 (0.9%) in Group B; none required intervention. Five pulmonary embolisms occurred in Group A (1.1%) and none in Group B. Seven patients in Group A (1.7%) and 6 (0.47%) in Group B had clinically evident DVT. Two non-VTE related deaths occurred in Group A. CONCLUSIONS: Adequate VTE prophylaxis is achieved using SCDs, early ambulation, emphasis on hydration, and shorter operating times. Bariatric surgery can be safely performed without pharmacologic VTE prophylaxis in all but the high-risk population. Fewer bleeding complications occur without the use of anticoagulants.

Cardiac tamponade as a life-threatening complication in hernia repair.

BACKGROUND: The placement of mesh in the repair of all types of hernia has been reported to decrease recurrence rates. There are several well known complications related to mesh repairs, including infection, erosion, seroma, and pain. Lesser reported are cardiac injuries secondary to anchoring of the mesh to the diaphragm. METHODS: We report 2 previously unreported, unpublished cases of cardiac tamponade after mesh fixation to the diaphragm and present a review of the literature and search of the US Food and Drug Administration's Manufacturer and User Device Experience (MAUDE) database. RESULTS: We reviewed a total of 10 cases of cardiac tamponade in hiatal hernia repair, 6 resulting in patient mortality, 5 cases in ventral hernia repair, 4 being fatal. Ten cases were caused by the helical tacker, 2 by sutures, 1 by the straight stapler, and in 1 case the cause was not identified. CONCLUSION: When anchoring mesh to the diaphragm, it is necessary to consider the risk of injury to the heart and cardiac tamponade, especially if the helical tacker is used in this region. Only with appropriate awareness and recognition can this catastrophic complication be avoided.

A survey of dumping symptomatology after gastric bypass with or without lesser omental transection.

BACKGROUND: Lesser omental transection during gastric bypass for morbid obesity may be associated with postoperative dumping. A survey of postoperative symptoms was performed in patients undergoing laparoscopic Roux-en-Y gastric bypass with transection vs. preservation of the lesser omentum. METHODS: A written questionnaire on dumping symptoms was administered to patients 2 years after laparoscopic Roux-en-Y gastric bypass with or without transection of the lesser omentum. Statistical testing was performed to determine whether the rate of various symptoms was related to the transection of the lesser omentum. RESULTS: The patients without lesser omental transection had significantly less symptoms than the patients with transection for 11 out of the 17 symptoms that were queried (p < 0.05). Ingestion of sweets was associated with dumping symptoms more frequently in the group of transected patients, and this group also had a lower frequency of sweet eating (p < 0.05). CONCLUSION: This study demonstrated that transection of the lesser omentum during laparoscopic-gastric bypass was associated with more postoperative dumping symptoms compared to bypass with preservation of the lesser omentum. This association may be secondary to a partial vagotomy that may occur if the lesser omentum is transected during gastric bypass.

Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up.

BACKGROUND: The management of high-grade esophageal dysplasia has included surveillance, endoscopic ablative techniques, and esophagectomy. Herein we describe an alternative treatment, laparoscopic transgastric esophageal mucosal resection. METHODS: Laparoscopic transgastric esophageal mucosal resection was accomplished through an anterior gastrotomy. The mucosa was stripped from the Z-line to the proximal extent of the abnormal epithelium. The gastrotomy then was closed with a linear stapler, and a Nissen fundoplication was performed. RESULTS: Six patients with high-grade dysplasia of the distal esophagus underwent mucosal resection. After 4 to 7 years of endoscopic surveillance, all patients have regenerated squamous epithelium. One patient developed nondysplastic Barrett's esophagus after 2 years and was treated medically. Two strictures were treated successfully with dilatation. CONCLUSIONS: Laparoscopic transgastric esophageal mucosal resection was a reasonable treatment for high-grade dysplasia in this small sample of patients. This technique is a potential alternative treatment for high-grade dysplasia of the esophagus.

Hiatal hernia repair with mesh: a survey of SAGES members.

BACKGROUND: Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh may reduce this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. A survey of surgeon practice was undertaken to obtain a better understanding of the controversies surrounding this clinical problem. METHODS: A questionnaire on the technique and results of mesh hiatal herniorrhaphy was sent to 1,192 members of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES). RESULTS: There were 275 responses; 261 of these were analyzed. A total of 5,486 hiatal hernia repairs with mesh were reported; 77% and 23% were performed laparoscopically vs open, respectively. The most common indication for mesh usage was an increased size hiatal defect (46% of respondents). The most common mesh types were biomaterial (28%), polytetrafluoroethylene (25%), and polypropylene (21%). Suture anchorage was the most common fixation technique (56% of respondents). The findings showed a failure rate of 3%, a stricture rate of 0.2%, and an erosion rate of 0.3%. Biomaterial tended to be associated with failure, whereas nonabsorbable mesh tended to be associated with stricture and erosion. CONCLUSIONS: The use of mesh during hiatal hernia repair resulted in a reported recurrence rate which appeared to be lower than that obtained historically without mesh. No one mesh type was clearly superior in terms of avoiding failure and complication.

Laparoscopic revision of failed fundoplication and hiatal herniorraphy.

OBJECTIVE: The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND: Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS: A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS: Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION: Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Nonsurgical skills do not predict baseline scores in inanimate box or virtual-reality trainers.

INTRODUCTION: Laparoscopic basic skills are best trained in the nonclinical setting. Box trainers and virtual-reality trainers have been shown to be useful in training laparoscopic skills. Certain nonsurgical skills may predict baseline skills in these trainers. This study tested the hypothesis that baseline scores could be predicted in inanimate box trainers and virtual-reality trainers by nonsurgical skills. METHODS: Only preclinical medical students were included in the study. All students were given a survey ascertaining if they played computer games, typed, sew, played a musical instrument, and utilized chopsticks. Students utilized a box trainer (BT) and/or virtual-reality trainer (VR). Nonparametric two-tailed Mann-Whitney tests were utilized to compare students that possessed certain nonsurgical skills versus those who did not. RESULTS: There were 18 students in the VR group and 33 students in the BT group. In the VR group, students who played computer games, typed, utilized chopsticks, or played a musical instrument had better scores and fewer errors than those who did not but this did not reach statistical significance in any comparison (p = NS). In the BT group, none of the nonsurgical skills predicted times or errors. Males performed better than females in the VR group (p < 0.001); but this gender discrepancy was not seen in the BT group. CONCLUSIONS: Nonsurgical skills do not predict baseline scores in either trainer. The gender differences in VR training need to be further explored.

Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit.

OBJECTIVE: We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction. METHODS: We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004. RESULTS: Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omentopexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months. CONCLUSIONS: Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.

Substituting virtual reality trainers for inanimate box trainers does not decrease laparoscopic skills acquisition.

OBJECTIVES: Inanimate and virtual reality box training help in developing basic laparoscopic skills. The lack of tactile feedback and lack of reality may be a detriment when training with virtual reality trainers. This study examined the hypothesis that there is no difference in laparoscopic skills acquisition when virtual reality trainers are partially substituted for inanimate box trainers. METHODS: Medical students without laparoscopic experience were randomized into either Group A or Group B. Group A performed tasks on the LTS 2000 (an inanimate box trainer) alone for 10 sessions. Group B performed tasks on the box trainer as well as on the MIST-VR (a virtual reality trainer) for 10 sessions. Scores for 5 inanimate box trainer exercises (time and errors) for the first and tenth sessions were compared between both groups. RESULTS: No statistical differences were seen in any exercises in the first session between Group A (n=14) and Group B (n=18) in either time or errors (P=NS for all comparisons). Mean times decreased in both groups from the first session to the last session. At the last session, again both groups demonstrated no differences in any of the exercises (P=NS for all comparisons). CONCLUSIONS: No difference was found in laparoscopic skills acquisition when incorporating virtual reality trainers into a curriculum based on inanimate box trainers. Ideally, laparoscopic training laboratories should include both virtual reality and inanimate trainers.

Laparoscopic repair of incarcerated diaphragmatic hernia with mesh.

Diaphragmatic hernias are now being approached laparoscopically. Incarcerated diaphragmatic hernia poses a special problem due to concerns about contamination. We describe a laparoscopic repair of such a hernia with the use of prosthetic mesh.

Laparoscopic Roux-en-Y Gastric bypass utilizing the triple stapling technique.

OBJECTIVE: To evaluate the outcomes of a single surgeon's experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) utilizing the triple stapling technique for creation of the jejunojejunostomy. METHODS: A retrospective review of patients who underwent LRYGB utilizing the triple stapling technique for creation of the jejunojejunostomy (JJ) between 10/01 and 12/04 was performed. RESULTS: LRYGB was performed in 435 consecutive patients. The mean age was 41 years (range, 14 to 68), and 82% were female. Mean initial body mass index was 50 (range, 35 to 91). One conversion to open (0.2%) was necessary. Mean operating time was 144+/-26 minutes. Mean length of stay was 2.3+/-1.5 days. There were 3 leaks at the gastrojejunostomy anastomosis (0.7%). No leaks occurred at the JJ anastomosis. One patient underwent revision of the JJ (0.2%) secondary to obstruction of the JJ on upper gastrointestinal study. Intraluminal bleeding occurred in 21 patients (4.8%). Patients required blood transfusion of 2.2+/-1.1 units (range, 0 to 5), but none required surgical or endoscopic intervention. Mortality occurred in 2 patients (0.5%). Mean excess body weight loss was 72% at 1 year. CONCLUSION: Construction of the jejunojejunostomy utilizing the triple stapling technique is expeditious, safe, and associated with minimal complication.

Survey of minimally invasive surgery fellowship programs.

INTRODUCTION: Since there was no accrediting body for minimally invasive surgery fellowships, this investigation was performed to characterize minimally invasive surgery fellowships. MATERIALS AND METHODS: All minimally invasive surgery fellowships that were noted on the Society of American Gastrointestinal Endoscopic Surgeons website in July 2002 were sent a survey. Only those fellowships that had fellow(s) for the year 2001-2002 were included in the survey. All programs were contacted a second time if the survey was not returned. Incomplete responses were not included in the data. RESULTS: There were 78 fellowships listed, of which 16 had no fellow in 2001-2002, one which was not a minimally invasive surgery fellowship, and one which was listed twice. Of the 19 (32%) programs that responded, there was an average of 1.3 clinical fellows per program (range, 1-3). All clinical fellowships were of one year duration. There was an average of 3.2 attendings for each program. Thirty-two percent of program directors had attended a laparoscopic fellowship. The average program received 50 applications and interviewed 12 applicants for the year 2001-2002. The average fellow had 14 (range, 0-42) manuscripts, abstracts, and/or presentations either completed or in progress. Average minimally invasive cases performed was bariatric 95, colon 33, solid organ (liver, spleen, kidney, adrenal) 32, antireflux 36, hernia 54, and endoscopy 48. However, the range of these cases varied and the lowest number of cases for each category was bariatric 5, colon 3, solid organ 8, antireflux 1, hernia 6, and endoscopy 0. CONCLUSION: Minimally invasive surgery fellowships seem to be competitive for surgical residents. These fellowships vary in both research and clinical experience.

Postoperative gastrointestinal complaints after laparoscopic Nissen fundoplication.

OBJECTIVES: Approximately 80% of patients complain of various symptoms immediately after laparoscopic Nissen fundoplication. These symptoms typically are treated medically without an extensive evaluation to identify the cause. We reviewed our experience of laparoscopic Nissen fundoplication to determine the course of postoperative symptomatology in our patient population, and present a rational approach to this problem. METHODS: Over a 10-year period, 628 patients underwent primary laparoscopic Nissen fundoplication for gastroesophageal reflux disease; patients were evaluated with a standard set of questions for postoperative gastrointestinal complaints. Three- and 6-month follow-up data were compared by using the chi square test. RESULTS: One-year follow-up data were available for 615 patients (98%). All of these patients had symptoms during the first 3 postoperative months. Early satiety (88%), bloating/flatulence (64%), and dysphagia (34%) were the most common; however, 94% of patients had resolution of their symptoms by the 1-year follow-up visit, and most had resolved after 3 months. Patients with persistent reflux or dysphagia after 3 months typically had an anatomic failure of the operation. CONCLUSIONS: Most patients who have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease will have gastrointestinal complaints during the initial 3 postoperative months. Nearly all of these patients will have resolved their symptomatology after 3 months. Those with persistent symptoms after 3 months warrant evaluation for operative failure.

Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass.

BACKGROUND: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. METHODS: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. RESULTS: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. CONCLUSION: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.

Laparoscopic repair of congenital duodenal obstruction.

CHARGE syndrome (or association) refers to a group of physical abnormalities occurring together: coloboma, heart defect, atresia choanae, retarded growth and development, genital hypoplasia, and ear anomalies/deafness. We report the successful use of laparoscopy in a patient with CHARGE syndrome and congenital duodenal obstruction.

L5-S1 laparoscopic anterior interbody fusion.

OBJECTIVE: We evaluated our experience with laparoscopic L5-S1 anterior lumbar interbody fusion (ALIF). METHODS: This represents a retrospective analysis of consecutive patients who underwent L5-S1 laparoscopic ALIF between February 1998 and August 2003. RESULTS: Twenty-eight patients underwent L5-S1 LAIF (15 males and 13 females). The mean age was 43 years (range, 26 to 67). Mean operative time was 225 minutes (range, 137 to 309 minutes). No conversions to an open procedure were necessary. Twenty-four (85.7%) patients underwent successful bilateral cage placement. Four patients (14.3%) in whom only a single cage could be placed underwent supplementary posterior pedicle screw placement. Mean length of stay (LOS) was 4.1 days (range, 2-to 15). Two patients underwent reoperation subacutely secondary to symptomatic lateral displacement of the cage. One patient developed radiculopathy 6 months postoperatively and required reoperation. One patient developed a small bowel obstruction secondary to adhesions to the cage requiring laparoscopic reoperation. Fusion was achieved in all patients. Visual analogue scale scores for back pain were significantly improved from 8.6+/-0.8 to 2.8+/-0.8 (P<0.0001) at 1 year. CONCLUSION: L5-S1 LAIF is feasible and safe with all the advantages of minimally invasive surgery. Fusion rates and pain improvement were comparable to those with an open repair.

Effects of a laparoscopic course on student interest in surgical residency.

BACKGROUND: The number of surgical residency applicants has been declining. Early introduction of the discipline of surgery is thought to stimulate early interest in surgical residency. This study investigated the hypothesis that a laparoscopic skills course introduced in preclinical years would stimulate student interest in entering surgical residency. METHODS: Preclinical medical students participated in a laparoscopic skills training course. All students underwent an animate laboratory at the beginning and at the end of the course. Students were divided into 4 separate groups: virtual reality, box trainer, both trainers, and control group. Before and after the course, students were asked their residency interest. First- and second-year medical students participated in the course. RESULTS: Before the course, 56% of the students desired to go into general surgery or a surgical subspecialty. After the course, 49% of the students expressed interest in entering general surgery or a surgical subspecialty. A decrease occurred in students who desired to go into surgical subspecialty residency from 31% to 15% (P = NS), and an increase occurred in students who desired to go into general surgery residency from 25% to 34% (P = NS). No statistically significant difference was seen in the 4 individual training subgroup analyses. CONCLUSIONS: Participation in a laparoscopic skills course does not affect medical student interest in entering surgical residency. A trend was noted in students choosing general surgery over surgical subspecialty training after this course. Surgical educators need to investigate methods to encourage preclinical medical student interest in surgical residencies.

Participants' opinions of laparoscopic training devices after a basic laparoscopic training course.

BACKGROUND: Basic laparoscopic skills are initially best taught and practiced in an inanimate setting. Various devices are used to aid in this education of laparoscopic skills. These devices range from simple box trainers to sophisticated virtual reality trainers. This investigation tested the hypothesis that participants would prefer one trainer to another trainer. METHODS: Preclinical medical students volunteered for this study. All underwent a porcine laboratory. The students were then divided into 3 groups by method of training: group A--a virtual reality trainer (MIST-VR), group B--an inanimate box trainer (LTS 2000), and group C--both trainers. Each group participated in 10 laboratories with the assigned trainer(s). After completion of the laboratories, all students underwent a similar porcine laboratory. During this laboratory, opinions of each trainer and specific tasks were ascertained from each student. RESULTS: No statistical difference was seen between groups A and B when asked if their specific trainer helped their skills, was realistic, helped in the animal laboratory, and was interesting. When group C was asked the same questions about each trainer, no statistical difference was seen except that 47% thought the MIST-VR was not realistic as opposed to 0% who thought the LTS 2000 was not realistic (P <.003). The level of difficulty of each task correlated with how much the specific task helped in development of skills for both trainers (P <.0001). In group C, 89% of the participants thought the LTS 2000 helped more that the MIST-VR and 56% thought the LTS 2000 was more interesting than the MIST-VR. In addition, 83% of students in group C chose LTS 2000 when asked to pick only one trainer. CONCLUSIONS: While virtual reality trainers may have some advantages, most participants feel that inanimate box trainers help more, are more interesting, and should be chosen over virtual reality trainers if only one trainer is allowed. Further studies need to investigate if the opinions affect participants' utilization of these trainers.