Consumer-based technology for distribution of surgical videos for objective evaluation.

BACKGROUND: The Global Operative Assessment of Laparoscopic Skill (GOALS) is one validated metric utilized to grade laparoscopic skills and has been utilized to score recorded operative videos. To facilitate easier viewing of these recorded videos, we are developing novel techniques to enable surgeons to view these videos. The objective of this study is to determine the feasibility of utilizing widespread current consumer-based technology to assist in distributing appropriate videos for objective evaluation. METHODS: Videos from residents were recorded via a direct connection from the camera processor via an S-video output via a cable into a hub to connect to a standard laptop computer via a universal serial bus (USB) port. A standard consumer-based video editing program was utilized to capture the video and record in appropriate format. We utilized mp4 format, and depending on the size of the file, the videos were scaled down (compressed), their format changed (using a standard video editing program), or sliced into multiple videos. Standard available consumer-based programs were utilized to convert the video into a more appropriate format for handheld personal digital assistants. In addition, the videos were uploaded to a social networking website and video sharing websites. RESULTS: Recorded cases of laparoscopic cholecystectomy in a porcine model were utilized. Compression was required for all formats. All formats were accessed from home computers, work computers, and iPhones without difficulty. Qualitative analyses by four surgeons demonstrated appropriate quality to grade for these formats. CONCLUSIONS: Our preliminary results show promise that, utilizing consumer-based technology, videos can be easily distributed to surgeons to grade via GOALS via various methods. Easy accessibility may help make evaluation of resident videos less complicated and cumbersome.

Intraoperative endoscopy and leaks after laparoscopic Roux-en-Y gastric bypass.

Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant (P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.

The candidate gene approach to susceptibility for abdominal aortic aneurysm: TIMP1, HLA-DR-15, ferritin light chain, and collagen XI-Alpha-1.

There are two approaches to gene discovery for diseases when genetic susceptibility has been implicated by clinical genetic or case-control studies: (1) genome-wide screening and (2) evaluation of candidate genes. Each has specific advantages and disadvantages. The principal advantage of genome-wide screening is that it is impeccably objective in as much as it proceeds without any presuppositions regarding the importance of specific pathobiological features of the disease process. The principal disadvantage is that such a study is expensive and resource intensive. A large population of enrolled patients and multidisciplinary teams of investigators cooperating from several institutions are usually required. The alternative approach of evaluating candidate genes can be pursued by a small independent laboratory with limited funding and resources, a small collection of clinical specimens, and a small number of team players. The disadvantage is that it is by necessity highly subjective in the process of selecting specific candidates among many reasonable possibilities. There is no a priori assurance that effort will not be expended on one or more candidates that turn out in the end to be failures. This report reviews efforts in our laboratory to evaluate four genes as candidates. One of these tissue inhibitor of metalloprotease 1(TIMP1) led to the description of a polymorphism, but not a conclusive mutation. The other three (HLA-DR-15, ferritin light chain (FTL), and collagen XI-alpha-1 (COL11A1) are subjects of continuing interest.

Three-year experience with totally endoscopic robotic thymectomy.

BACKGROUND: : Robotic technology has facilitated the evaluation and treatment of anterior mediastinal pathology. We describe a 3-year experience using the da Vinci Robotic Surgical System to perform thymectomies for a range of diseases. METHODS: : From March 2002 to November 2004, 9 patients (3 myasthenia gravis, 3 mediastinal mass, 2 myasthenia gravis plus thymoma, 1 hyperparathyroidism) underwent totally endoscopic robotic thymectomy. Medical records and operative databases were reviewed. The cohort was divided into an early experience (group A) and a later experience (group B). Data were analyzed with the Fisher exact test and Mann-Whitney test. RESULTS: : Complete robotic resection of the thymus was accomplished in all 9 patients. The mean age for the entire cohort was 40 ± 12 years (range 28-66 years) and 78% of the patients were women. No significant differences in age, gender, or operative conversions were detected between the groups. Patients in group A were more likely to have a bilateral approach. Group B demonstrated statistically significant reductions in operating room and operation time and a trend toward decreased chest tube days and length of stay. No morbidity or mortality associated with the procedure was noted in either group. CONCLUSIONS: : Robotic thymectomy is a safe and effective procedure. Its steep learning curve promises to allow more surgeons to adopt minimally invasive approaches to the mediastinum safely and efficiently.

Midterm Follow-up of Robotic Biventricular Pacing Demonstrates Excellent Lead Stability and Improved Response Rates.

BACKGROUND: : Robotically assisted left ventricular (LV) lead placement is an effective minimally invasive rescue procedure for cardiac resynchronization in the setting of failed coronary sinus lead insertion. The long-term response rate and durability of this technique has not been reported. The authors evaluated the midterm outcome of biventricular pacing performed with robotically placed LV leads. METHODS: : Forty-two patients underwent implantation of LV epicardial leads using robotic assistance and the posterior approach. Half of the patients had prior cardiac surgery. All leads were placed in an optimal site along the posterolateral surface of the LV. The patients were prospectively followed up for clinical response, LV reverse remodeling, and LV lead stability over a mean period of 16.7 ± 9.5 months (range, 3-34 months). A multivariate Cox proportional hazards model was used to determine predictors of response. RESULTS: : All patients had successful LV lead placement with no postoperative mortality. Statistically significant improvements in left ventricular ejection fraction, NYHA heart failure class, systolic left ventricular internal dimension index, and diastolic left ventricular internal dimension index. The 3-month clinical response rate was 81% and dropped to 71% at average maximal follow-up. Multivariate analysis of 9 variables revealed only LVEF greater than 15% and absence of pulmonary hypertension to be predictors of response. No difference in operative time, response rate, or LV lead stability was detected when primary versus reoperative cases were compared. CONCLUSIONS: : Robotic LV lead placement is a reliable technique for optimal lead placement with durable long-term results.

The LapSim: a learning environment for both experts and novices.

BACKGROUND: Simulated environments present challenges to both clinical experts and novices in laparoscopic surgery. Experts and novices may have different expectations when confronted with a novel simulated environment. The LapSim is a computer-based virtual reality laparoscopic trainer. Our aim was to analyze the performance of experienced basic laparoscopists and novices during their first exposure to the LapSim Basic Skill set and Dissection module. METHODS: Experienced basic laparoscopists (n=16) were defined as attending surgeons and chief residents who performed >30 laparoscopic cholecystectomies. Novices (n=13) were surgical residents with minimal laparoscopic experience. None of the subjects had used a computer-based laparoscopic simulator in the past. Subjects were given one practice session on the LapSim tutorial and dissection module and were supervised throughout the testing. Instrument motion, completion time, and errors were recorded by the LapSim. A Performance Score (PS) was calculated using the sum of total errors and time to task completion. A Relative Efficiency Score (RES) was calculated using the sum of the path lengths and angular path lengths for each hand expressed as a ratio of the subject's score to the worst score achieved among the subjects. All groups were compared using the Kruskal-Wallis and Mann-Whitney U-test. RESULTS: Novices achieved better PS and/or RES in Instrument Navigation, Suturing, and Dissection (p<0.05). There was no difference in the PS and RES between experts and novices in the remaining skills. CONCLUSION: Novices tended to have better performance compared to the experienced basic laparoscopists during their first exposure to the LapSim Basic Skill set and Dissection module.

A novel drill set for the enhancement and assessment of robotic surgical performance.

BACKGROUND: There currently exist several training modules to improve performance during video-assisted surgery. The unique characteristics of robotic surgery make these platforms an inadequate environment for the development and assessment of robotic surgical performance. METHODS: Expert surgeons (n=4) (>50 clinical robotic procedures and >2 years of clinical robotic experience) were compared to novice surgeons (n=17) (<5 clinical cases and limited laboratory experience) using the da Vinci Surgical System. Seven drills were designed to simulate clinical robotic surgical tasks. Performance score was calculated by the equation Time to Completion + (minor error) x 5 + (major error) x 10. The Robotic Learning Curve (RLC) was expressed as a trend line of the performance scores corresponding to each repeated drill. RESULTS: Performance scores for experts were better than novices in all 7 drills (p<0.05). The RLC for novices reflected an improvement in scores (p<0.05). In contrast, experts demonstrated a flat RLC for 6 drills and an improvement in one drill (p=0.027). CONCLUSION: This new drill set provides a framework for performance assessment during robotic surgery. The inclusion of particular drills and their role in training robotic surgeons of the future awaits larger validation studies.

Mid-term results and patient perceptions of robotically-assisted coronary artery bypass grafting.

We sought to study our mid-term outcomes and our patient's perceptions of robotically-assisted coronary artery bypass (RACAB). The daVinci robotic system was utilized to harvest and prepare the internal thoracic artery (ITA) as well as to open the pericardium and identify the target vessels. Anastomoses were performed by hand on the beating heart through limited incisions using an endoscopic stabilizing device. A follow-up telephone interview was conducted with patients at 3 to 6 months. Between 4/12/02 and 11/1/04, 37 patients underwent RACAB (1.2 distal anastomoses/patient). Median length of stay was 3 days (2-14 days) and 82% of patients reported full return to baseline activity within 10 days of surgery. There were two early LITA complications and one late anastomotic stenosis all of which occurred within the first two cases of each surgeon's experience. The majority of patients surveyed (95%) knew that robotics were involved in their surgery and most patients (95%) would recommend RACAB (95%). RACAB is an effective minimally invasive revascularization technique with excellent recovery times and high patient satisfaction. The early complication rate emphasizes the steep learning curve for this procedure as well as the need for intensive pre-procedure training.