Effects of Fatigue on Residents' Performance in Laparoscopy.

BACKGROUND: The influence of fatigue on residents' performance in laparoscopy was prospectively assessed through a computer-based virtual reality simulation (VRS) model. STUDY DESIGN: Twenty-six residents (14 novices, 12 experienced) were recruited. In the first stage, each participant was initially tested on 8 VRS-based tasks. In the second, run-in stage, each resident had 8 hours of hands-on practice of the specific tasks chosen. Finally, participants were evaluated before and after 24 hours on call. For each task, a set of parameters reflecting proficiency, efficacy, and safety were documented. RESULTS: In most of the tasks assessed, sleep deprivation had a significant deleterious effect on the performance of residents, both in terms of efficiency (time to complete the task), and safety (errors). These observations were more pronounced among novices. For example, in camera manipulation at a 30-degree angle, the total time to complete the task was slower after sleep deprivation (novices: sleep deprivation = 136 seconds, control = 119 seconds; experienced: sleep deprivation = 112 seconds, control = 103 seconds; p = 0.03). Moreover, accuracy rates were lower after sleep deprivation: in the "grasping and clipping" task, a lower accuracy rate after sleep deprivation was noted (novices: sleep deprivation = 82.8%, control = 87.9%; experienced: sleep deprivation = 87.6%, control = 90.8%; p = 0.05). CONCLUSIONS: In this prospectively controlled study we observed reduced efficiency and safety in the performance of residents after sleep deprivation. Using an innovative study design, we eliminated the learning curve bias. Compared with novices, experienced residents performed relatively better after a night shift, and this may be attributed to better adaptation to sleep deprivation.

Insertion of removable self-expanding metal stents as a treatment for postoperative leaks and perforations of the esophagus and stomach.

BACKGROUND: Esophageal perforations and postoperative esophageal leaks are associated with substantial morbidity and mortality and pose a difficult therapeutic challenge. OBJECTIVES: Toevaluate the outcome ofremovableself-expanding metallic stents (SEMS) as a treatment for postoperative leaks and perforations of the esophagus and stomach. METHODS: We conducted a retrospective study of all patients in one medical center who underwent temporary insertion of a covered plastic stent for postoperative leaks and perforations of the esophagus and stomach from June 2009 to February 2010. Data were retrieved from hospital and outpatient clinical data charts. Data included indication for insertion, post-insertion outcome including stent complications, and follow-up after stent removal. RESULTS: The indications for stent insertion were postoperative leak in four patients and postoperative esophagopleural fistula in one patient. Three of the patients had a leak at the gastroesophageal junction following laparoscopic sleeve gastrectomy. In all cases the stent insertion was completed successfully. In three patients the stent migrated distally. In two of these three it was repositioned or replaced endoscopically, and in the third it was excreted in the feces. Stents were removed electively after 6 to 7 weeks. All patients recovered fully and were discharged from the hospital. CONCLUSIONS: SEMS insertion may have an important role in the management of postoperative leaks and perforations of the esophagus and stomach and should be considered in such cases.

Laparoscopic inguinal hernioplasty in aviators.

Repair of inguinal hernias may be performed using either open surgery or laparoscopic techniques. Following surgery, a 6-wk waiting period is generally recommended before a pilot returns to active duty, including flight in high-performance aircraft. A shorter waiting period would be operationally useful and may be possible following either a trans-abdominal preperitoneal (TAPP) laparoscopic technique or a totally extra-peritoneal (TEP) approach. In this manuscript we present the cases of four aviators who underwent inguinal hernia repair via the TEP approach and were returned to the cockpit 21 d later with no evident complications. Although this sample is small, it emphasizes the potential benefit of the TEP approach in aviators.