Is laparoscopic experience helpful in simulator based robotic training in general surgery?

OBJECTIVE: To evaluate whether or not prior laparoscopic training improves performance during robotic surgery utilising DaVinci robotic skills simulator. METHODS: The cross-sectional study was conducted at the Civil Hospital, Karachi, from May 4 to November 11, 2018, and comprised first year residents in Group A with no laparoscopic skills and fourth year residents doing laparoscopic cholecystectomy independently and surgical faculty members in Group B who had laparoscopic skills. Both the groups had no previous exposure to robotic surgery and skills simulator. There were 4 exercises which were repeated three times by each participant. Scoring was done using the DaVinci robotic skills simulator software. Data was analysed using SPSS 22. RESULTS: Of the 30 surgeons, there were 15(50%) in Group A with a mean age of 26±0.56 years, and 15(50%) in Group B with a mean age of 32 ± 9.16 Years (p<0.001). The overall mean age was 32±9.16 years (range: 25-52 years). There were 19(63.3) females in the sample compared to 11(36.6%) males. Mean scores of Ring walk 2, Peg board 2, and Suture sponge 3 were better in Group A, while mean score of Matchboard 2 was better in Group although B (p>0.05). Group B fared better in the individual scoring of Suture sponge 2 (p>0.05). CONCLUSIONS: Laparoscopic skills apparently did not confer any benefit while performing exercises on the DaVinci skills simulator.

A comparative follow up study of transabdominal preperitoneal mesh repair in inguinal hernias with or without mesh fixation.

OBJECTIVE: To compare the recurrence rate and chronic pain in hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation with and without mesh. METHODS: The prospective comparative study was conducted at Surgical Units 4 and 5 of the Civil Hospital, Karachi, from August 1, 2017, to July 1, 2018, and comprised hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation who were randomised into fixation Group A and non-fixation Group B. Postoperative visual analogue scale score was calculated at the time of discharge. At 1-year follow-up, recurrence rate and chronic pain were assessed. Data was analysed using SPSS 23. RESULTS: Of the 98 patients, there were 49(50%) in each of the two groups. Of the total, there were 97(99%) males. The overall mean age was 44.52±14.51 years. The differences in visual analogue scale scores at the time of discharge and the mean discharge from the hospital in terms of days were statistically significant (p<0.005). At 1-year follow-up, there was recurrence in 1(1.02%) case and that was in Group A (p>0.05). Chronic pain between the groups was not significant (p>0.05). CONCLUSION: There was no significant difference in terms of recurrence and chronic pain between mesh and non-mesh fixation.

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre.

OBJECTIVE: To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. METHODOLOGY: Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p ² 0.05. Odds ratio was calculated for the qualitative data using 95% confidence interval. RESULTS: Age of the study population ranged from 9 to 90 years (mean age 46.5 ± 14.94 years, median 45 years). Male to female ratio was 1:1.87. Pancreatitis was seen in 18 patients (3.6%), mild in 15 (3%), moderate in one (0.2%) and severe in 2 (0.4%). Mean amylase level at 4 hours and 24 hours was 280.93 ± 539.13 and 168.83 ± 338.34 respectively. Pancreatitis was seen in 15/326 (4.6%) females and 3/174 (1.72%) males. Statistically significant increased risk for pancreatitis was seen in difficult cannulation (9.8%, p = 0.006), prolonged cannulation time (7.6 minute, p = 0.002), pancreatic duct cannulation (13.7%, p = 0.001) and pancreatic duct contrast injection (13.4%, p < 0.001). CONCLUSION: The frequency of post-ERCP pancreatitis was 3.6%. Difficult cannulation, pancreatic duct cannulation, pancreatic duct contrast injection and balloon sphincteroplasty were associated with higher frequency of post-ERCP pancreatitis. Reuse of ERCP accessories poses no additional risk to the frequency of pancreatitis.

Endoscopic retrograde cholangiopancreatography: a therapeutic modality in children and adolescents.

OBJECTIVE: To evaluate the indications, clinical features, complications, and effect on patient management of Endoscopic retrograde cholangiopancreatography (ERCP) in paediatric patients of varying age. METHODS: A prospective, descriptive cross sectional study was conducted at the endoscopy suite, Surgical Unit 4, Civil Hospital Karachi; from January 2007 to August 2010. All ERCPs performed during a 3-year period in patients aged 18 years or less were prospectively analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy. RESULTS: A total of 40 children and adolescents (18 Males, 22 Females; mean age 13.6 +/- 3.37 years, range 3 to 18 years) underwent 52 ERCP procedures. Indications were biliary pathology in 21, and pancreatic pathology in 19. The ERCP findings were choledocholithiasis in 12 patients, choledochal cysts in 5, chronic pancreatitis in 8, pancreatic pseudocyst in 5, recurrent pancreatitis in 5, biliary ascariasis in 2, pancreatic divisum in 1, postoperative bile leak in 1, and benign biliary stricture in 1. ERCP was successful in 51 of 52 procedures. Single procedure was performed in 36 patients, where as two patients required 2 procedures and it was repeated 4 and 6 times in the remaining two patients. Endoscopic therapy was performed in 92% of the procedures. The complication rate was 1.9% (1/52 procedures) which included mild pancreatitis, whereas asymptomatic hyperamylasaemia was seen in 11% (6/52 procedures). No mortality related to ERCP occurred. ERCP affected management in 94% (49/52 patients). CONCLUSION: ERCP is an effectual and safe therapeutic procedure in children and adolescents of different ages with a variety of pancreatobiliary disorders.

Endoscopic management of post operative bile duct injuries.

OBJECTIVE: To evaluate the pattern of post-operative bile duct injuries and their subsequent endoscopic management. METHODS: The prospective, non-randomised, cross-sectional study was conducted at the endoscopic suite of Surgical Unit-IV of the Civil Hospital, Karachi, over a period of three years. A total of 97 patients were included in the study. Post-procedure patients were followed up for resolution of symptoms and cessation of the bile leak. Patients with complete biliary cutoff or transection on Endoscopic Retrograde Cholaugio-Paucreatography (ERCP) were advised Magnetic Resonance Cholaugio-Papereatography (MRCP). Average followup of patients in our study was for 3 months. Mann Whitney U test was applied for non-parameteric data. RESULTS: Out of 97 patients in the study, 82 (84.5%) presented with post-operative bile leakage and 15 (15.5%) with obstructive jaundice. The age of the study population ranged between 20-70 years with a mean age of 40.80 +/- 13.45 years. Male-to-female ratio was 1:3. ERCP findings in our study included 41 (42.26%) patients with bile leakage out of which 27 (27.8%) had high-grade leak and 5 (5.1%) had low-grade leak, while 9 (9.3%) patients had Common Bile Duct (CBD) stones. Among the patients, 39 (40.2%) had complete cutoff of CBD. There were 15 patients with strictures and 6 with normal ERCP. As for the bile leads, 36/41 (87.8%) patients were managed successfully by endoscopic stenting, stone removal or simple sphincterotomy. Of the 41 patients, 5 (12.2%) with bile leak developed biliary stricture on subsequent ERCP. Nine of the 15 patients (60%) with complete cutoff on initial endoscopy were successfully stented on subsequent ERCP after demonstration of biliary continuity on MRCP. Six (40%) patients were referred for surgery. CONCLUSION: Patients with postoperative biliary leaks fare much better than those with complete cutoff or strictures. MRCP should be done in all patients where ERCP shows loss of biliary continuity. Re-exploration should be deferred till all other non-invasive modalities have been tried.

Benign esophageal strictures: behaviour, pattern and response to dilatation.

OBJECTIVE: To evaluate the endoscopic dilatation of benign esophageal strictures and its outcome. METHODS: A prospective descriptive study was conducted at Surgical Unit 4 of Civil Hospital Karachi, over a period of 24 months, from August 2006 to July 2008. Twenty seven patients with benign esophageal strictures underwent esophageal dilatation under fluoroscopic guidance using Savary Gilliard Dilators and guide wire. Follow up was done weekly for 2 weeks and monthly for a minimum of 6 months. Treatment success was gauged according to improvement of dysphagia. RESULTS: A total of 27 patients were included in the study. There were 16 (59.3%) corrosive strictures, 10 (37%) were peptic strictures and one (3.7%) was due to extrinsic compression. Majority of the corrosive strictures, 11 (68.75%) were suicidal in intent p < 0.001. Mean dilatation frequency for strictures longer than 5cms was 7.10 +/- 5.322 vs. 3.47 +/- 3.281 for strictures < 6cms (p < 0.037). Corrosive strictures were seen more commonly in the upper esophagus as compared to peptic (Mean 22.44 +/- 5.240 cm vs. 30.20 +/- 4.780 cm), p < 0.001. Only 81.4% corrosive stricture could be adequately dilated at initial dilatation as compared to 100% in peptic strictures. Mean symptomatic recurrences per month were 0.6919 +/- 0.300 in corrosives and 0.365 +/- 0.293 in peptic strictures (p < 0.003). There were 4 procedure related perforations, all in patients with corrosive strictures. Overall mortality was 7.4%. CONCLUSION: Endoscopic dilatation is safe and effective in treating benign and corrosive esophageal strictures, which have a higher complication rate. Mean recurrence rate decreased over a period of time in both peptic and corrosive strictures.

An experience of capsule endoscopy from a tertiary care hospital in Pakistan.

OBJECTIVES: To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding. METHODS: A prospective descriptive study was conducted at surgical unit IV, Civil Hospital Karachi over a period of 2 years from December 2007 to November 2009. Twenty eight consecutive patients presenting with obscure gastrointestinal bleeding were included in the study. Patients having history of acute intestinal obstruction were excluded. Study was approved by the hospital ethical committee. Informed and written consent was taken from all the patients included in the study. The procedure was performed as day case. Patients were asked to swallow a capsule with a glass of water after an overnight fast and bowel preparation. Endocapsule (Olympus MAJ-1469) was used in the study. Examination was termed as complete when the capsule reached the caecum or incomplete if capsule failed to enter the caecum or the battery life was exhausted. Computer recordings were read by two examiners and finally results were interpreted. Follow up was done on telephone every 24 hours till the passage of capsule and then monthly for 4 months. In case of failure to pass the capsule after 14 days or adverse effects like vomiting, abdominal pain, an abdominal radiograph was obtained and decision regarding surgical intervention was made. RESULTS: A total of twenty eight patients were included in this study, 15 (53.6%) males and 13 (46.4%) females. Age of the patients ranged from 15-85 years (mean 56.25 +/- 19.6 years). There were 8 (28.6%) diabetics, 8 (28.6%) hypertensives and 5 (17.9%) hepatitis C positive patients. The indication for the capsule endoscopy was malena in 9 (32.1%), occult bleed in 18 (64.3%) and non specific abdominal pain in 1 (3.6%). Examination was completed in 22/28 (78.6%) patients while 6 (21.4%) patients had incomplete examination. In 2/28 (7.1%) patients endoscopic assistance was required to push the capsule through the pylorus. There was history of abdominal surgery in 3/28 (10.7%) patients prior to capsule endoscopy. Capsule entrapment occurred in 2/28 (7.1%) patients who were subjected to surgery. The results of capsule endoscopy showed ulceration and bleeding in distal ileum in 7 patients followed by Arterio Venous Malformation in 6 patients. The management and follow up was done accordingly. CONCLUSION: The diagnostic yield of CE in this study was 64.28% (18/28 patients). In a total of 28 patients referred for capsule endoscopy, bleeding was resolved in 13 patients (46.42%). Capsule endoscopy is a well tolerated and safe examination of the small bowel with a diagnostic yield superior to radiological investigations.

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones.

OBJECTIVE: To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. METHODS: A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15 mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18 mm Controlled Radial Expansion (CRE) balloons. All procedures were done as day case under conscious sedation. RESULTS: There were 18 (21.4%) male and 66 (78.6%) females. Age of the study population ranged from 16-85 years with a mean of 48.38 +/- 17.07 years. The size of the stone ranged from 10-32 mm with a mean of 14.7 +/- 0.44 mm. Stones were removed with sphincteroplasty in first session in 52/84 (61.9%) patients, 11/17 (64.4%) patients in the second session and 4/4 (100%) in the third session. Patients who were lost to follow up were 14 (16.7%). Surgery was advised for 2 (2.4%) patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients (8.3%) while one (1.2%) died. Bleeding was encountered in 3 (3.6%) patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients (3.6%). None of the patients had severe pancreatitis or perforation secondary to the procedure. CONCLUSION: Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone.