Perceptions of Competition-Based Learning After a Brief Experience at a National Surgical Meeting.

BACKGROUND: Competition-based learning (CBL) facilitates learning through competitions. At the 2022 & 2023 Annual SAGES meetings, we evaluated a CBL experience (TOP GUN Shootout) developed from a modified version of the previously validated TOP GUN Laparoscopic Skills and Suturing Program. The project sought to evaluate the TOP GUN Shootout's (TGS) ability to enhance participant engagement in pursuit of laparoscopic surgical skills. METHODS: Participants competed in the TGS. Their scores (time and errors) were recorded for: Fundamentals of Laparoscopic Surgery Peg Pass, Cup Drop Task, and Intracorporeal Suturing. All participants completed a 10-question satisfaction survey on a 7-point Likert scale, with questions assessing 3 domains: (1) capability/confidence in MIS skill performance prior to the competition; (2) applicability and satisfaction with TGS's capacity to develop MIS skills; and (3) interest in seeking additional MIS training and appropriateness of CBL in MIS training. Descriptive statistics were used to evaluate these areas. RESULTS: Overall, 121 participants completed the TGS, of whom 84 (69%) completed the satisfaction survey. The average age was 32.9 years, 67% were males. On average (+/- SD), participant satisfaction was 5.04 (+/- 2.08) for Domain 1, 6.20 (+/- 1.28) for Domain 2, and 6.58 (+/- .95) for Domain 3. CONCLUSION: Participants described an overall lack of confidence in their MIS skills prior to the 2022-2023 Annual SAGES conference. Participants felt that this brief CBL experience, aided in the development of their MIS skills. Furthermore, this brief CBL experience may inspire learners to seek out further training of their MIS skills.

Addressing the gap in laparoscopic common bile duct exploration training for rural surgeons: imparting procedural ability is not enough.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is an underutilized therapy for choledocholithiasis. The driving factors of this practice gap are poorly defined. We sought to evaluate the attitudes and practice patterns of surgeons who underwent training courses using an LCBDE simulator. METHODS: Surgeons completed a half-day simulator-based LCBDE curriculum at national courses, including the American College of Surgeons Advanced Skills Training for Rural Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting. Attitudes were assessed with Likert surveys immediately before and after curriculum completion. Follow-up surveys were distributed electronically. RESULTS: 159 surgeons completed training during six courses. Surgeon attitudes regarding the overall superiority of LCBDE vs. ERCP shifted towards favoring LCBDE after course participation (4.0 vs 3.3; Likert scale 1-5, p < 0.001). 44% of surgeons completed follow-up surveys at a mean of 3 years post-course. Surgeons remained confident in their ability to perform LCBDE, with only 14% rating their skill as a significant barrier to practice, as compared with 43% prior to course participation (p < 0.01). However, only 28% of surgeons saw an increase in LCBDE volume. Deficiencies in operating room (OR) staff knowledge and instrument availability were the most significant barriers to post-course practice implementation and were inversely correlated with LCBDE case volume (ρ = - 0.44 and - 0.47, both p < 0.01). Surgeons for whom OR staff knowledge of LCBDE was not a significant barrier performed nearly 4 times more LCBDE than those who rated staff knowledge as a moderate, strong, or complete barrier. CONCLUSIONS: Surgeons trained at an LCBDE course retained long-term confidence in their procedural ability. Practice implementation was hindered by deficiencies in OR staff knowledge and instrument availability. Surgeons with knowledgeable operating room staff performed significantly more LCBDEs than those with less capable assistance. These barriers should be addressed in future curricula to improve procedural adoption.

A simulator-based resident curriculum for laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) remains an underused treatment for choledocholithiasis, likely in part because of a lack of exposure to the procedure during surgery residency. In this study, we implemented a resident LCBDE curriculum using a previously validated procedural simulator. METHODS: Senior surgery residents underwent a curriculum consisting of deliberate practice using the LCBDE simulator. Residents performed a simulated transcystic and transcholedochal LCBDE before and after completing the curriculum, which were rated by three faculty. Passing scores were determined using an Angoff method. RESULTS: Ten residents participated. For transcystic LCBDE, all 10 residents failed the pretest. Assessment scores improved after the curriculum (20 ± 4 vs 41 ± 2; scale 0-45, P < .01), and all 10 residents passed the posttest. For transcholedochal LCBDE, all 10 residents failed the pretest. Transcholedochal scores improved after the curriculum (27 ± 6 vs 46 ± 4; scale 0-53, P < .01). Eight residents passed the initial posttest and two failed because they sutured the t-tube into the choledochotomy closure. Both underwent remedial training and passed a retest. Resident confidence in performing LCBDE clinically improved for both transcystic and transcholedochal approaches. CONCLUSION: This curriculum improved the ability of surgery residents to perform both transcystic and transcholedochal LCBDE on a procedural simulator.

Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia.

BACKGROUND: Peroral esophageal myotomy (POEM) is a new endoscopic operation for the treatment of achalasia. Here, we report 1-year physiologic and symptomatic outcomes following the procedure. METHODS: POEM patients from a single-institution series who were more than 1 year removed from surgery were studied. Eckardt and GerdQ scores were obtained to assess symptoms. High-resolution manometry (HRM), timed barium esophagram (TBE), and upper endoscopy were preformed preoperatively and at 1-year follow-up. 24-h pH monitoring was also performed at 1 year follow-up. RESULTS: The study population was comprised of 41 patients who were more than 1 year post-POEM. One (2%) major complication, a contained leak at the EGJ requiring re-operation, and 7 (17%) minor complications occurred. Mean length of stay was 1.4 days. At mean 15-month follow-up, Eckardt scores improved from pre-POEM 7 ± 2 to post-POEM 1 ± 2, (scale 0-12, p < .001), and 92% of patients achieved treatment success (Eckardt score <4). Two of the three treatment failures in the series occurred in the initial three patients. 15% of patients had post-POEM symptoms suggestive of gastroesophageal reflux (GerdQ >7). On follow-up HRM, esophagogastric junction integrated relaxation pressure was decreased significantly (pre-POEM 28 ± 12 mmHg vs. post-POEM 11 ± 4 mmHg, p < .001), and 47% of patients studied had partial recovery of peristalsis. On follow-up TBE, barium column heights were decreased compared with preoperatively. Postoperative upper endoscopy revealed esophagitis in 59% of patients (11 LA Grade A, 2 LA Grade D). However, of the 13 24-h pH monitoring studies performed, only four (31%) demonstrated pathologic esophageal acid exposure. CONCLUSIONS: In this series, POEM resulted in greater than 90% symptomatic treatment success at mean 15-month follow-up. Rates of iatrogenic gastroesophageal reflux, as measured both by symptoms and 24-h pH monitoring, appeared to be on par with recent studies of patients undergoing laparoscopic Heller myotomy and pneumatic dilation.

Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM).

BACKGROUND: Peroral esophageal myotomy (POEM) is an endoscopic surgical operation for achalasia. Here, we analyze a single-series POEM learning curve and examine which preoperative patient factors are predictive of operative difficulty. METHODS: Two surgeons performed all POEM procedures conjointly. Nonlinear regression was used to determine the learning curve for procedure time. Preoperative patient characteristics were correlated with outcomes. RESULTS: Thirty-six POEM procedures were performed. Total operative time did not decrease over the course of the series (mean 112 ± 36 min). Time required to complete the procedural steps of submucosal access and myotomy did decrease with experience, both exhibiting a "learning rate" of seven cases. The incidence of inadvertent mucosal perforations and the number of clips required both decreased with experience. Postoperative Eckardt scores at 1-year follow-up decreased over the course of the series. Prior endoscopic treatment, symptom duration, and esophageal width were all independently predictive of longer procedure time. Preoperative symptom duration was also positively associated with inadvertent mucosal perforation and the number of clips required. CONCLUSIONS: In this series, overall procedure time did not decrease with experience and may not be an important marker of procedural skill for POEM. Prior endoscopic treatment, longer symptom duration, and esophageal dilatation may result in increased operative difficulty during POEM.

Management of intraoperative hemorrhage during NOTES: a prospective, randomized comparison.

BACKGROUND: The optimal strategy to manage intraoperative hemorrhage during NOTES is unknown. A randomized comparison of three instruments for hemorrhage control was performed [prototype endoscopic bipolar hemostasis forceps (BELA) vs. prototype endoscopic clip (E-CLIP) applier versus laparoscopic clip (L-CLIP) applier]. METHODS: A hybrid transvaginal NOTES model in swine was used, with hemorrhage induced in either the gastroepiploic (GE) arteriovenous bundle (vessel diameter ~3 mm) or in distal mesenteric vessels (vessel diameter ~1-2 mm). Hemostasis was attempted three times per vessel using each instrument in a randomized order. Full laparoscopic salvage was performed if hemorrhage persisted beyond 10 min. Outcomes included primary success rate (PS), primary hemostasis time (PHT), number of device applications (DA), and overall hemostasis time (OHT, including salvage). RESULTS: Seventy hemostasis attempts were made in 12 swine. PS was 42-67 % for the GE vessels, with no difference between instruments. PHT and OHT also were similar between instruments, with the BELA and L-CLIP having a higher number of DA. PS was (80-100 %) in mesenteric vessels, with the BELA and L-CLIP resulting in a shorter mean PHT compared with the E-CLIP. CONCLUSIONS: All three instruments had similar effectiveness in achieving primary hemostasis during hybrid NOTES. Management of small vessel bleeding (1-2 mm) in a porcine model is effective using all three instruments but may be most efficient with the BELA or L-CLIP. Large vessel bleeding (≥3 mm) may be best managed by adding laparoscopic ports for assistance while maintaining a low threshold for conversion to full laparoscopy.

Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy.

BACKGROUND: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. Few POEM outcome data exist, and no study has compared POEM with the surgical standard, laparoscopic Heller myotomy (LHM). METHODS: Perioperative outcomes were compared between POEM and LHM performed in a nonrandomized fashion. Patients in both groups met the following eligibility criteria: diagnosis of achalasia, age 18-85, and absence of prior achalasia treatment. RESULTS: Eighteen patients underwent POEM, and 55 patients underwent LHM. Operative times were shorter for POEM (113 vs. 125 min, p < .05), and estimated blood loss was less (≤10 ml in all cases vs. 50 ml, p < .001). Myotomy lengths, complication rates, and length of stay were similar. Pain scores were similar upon post-anesthesia care unit arrival and on postoperative day 1 but were higher at 2 h for POEM patients (3.5 vs. 2, p = .03). Narcotic requirements were similar, although fewer POEM patients received ketorolac. POEM patients' Eckardt scores decreased (median 1 postop vs. 7 preop, p < .001), and 16 (89 %) patients had a treatment success (score ≤3) at median 6-month follow-up. Six weeks after POEM, routine follow-up manometry and esophagram showed normalization of esophagogastric junction pressures and contrast column heights. CONCLUSIONS: POEM and LHM appear to have similar perioperative outcomes. Further investigation is needed regarding long-term results after POEM.

Fundamentals of laparoscopic surgery (FLS) manual skills assessment: surgeon vs nonsurgeon raters.

OBJECTIVE: The American Board of Surgery has recently started requiring completion of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) fundamentals of laparoscopic surgery (FLS) program for board certification in general surgery. Although most SAGES Testing Centers utilize nonsurgeons as FLS proctors, the effectiveness of using nonsurgeons as FLS proctors has not been evaluated. METHODS: Surgeons and nonsurgeons attending FLS proctor training workshops were studied. Participants reviewed training materials before course attendance. Subjects watched a videotaped FLS performance containing 9 "critical" errors, which participants were asked to identify. This assessment was repeated after hands-on training. RESULTS: Thirteen surgeon and 17 nonsurgeon subjects participated. At baseline, surgeons detected 66% of errors, vs 65% for nonsurgeons, with no statistical difference between groups. Analysis of individual tasks also showed no difference between groups, except for intracorporeal knot-tying (p = 0.049). Both groups improved after training (p < 0.01), with surgeons detecting 81% of errors vs 83% for nonsurgeons (no difference in overall or task-specific ratings). CONCLUSIONS: This study suggests that trained nonsurgeons may be as effective as surgeon proctors in detecting errors associated with the FLS manual test. This finding supports the utility of using trained nonsurgeons as FLS proctors as surgical training programs face increasing economic constraints.

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy.

INTRODUCTION: A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC). METHODS: Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.). RESULTS: Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively. CONCLUSIONS: This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.

Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is an effective, single-stage treatment for choledocholithiasis. However, LCBDE requires specific cognitive and technical skills, is infrequently performed by residents, and currently lacks suitable training and assessment modalities outside of the operating room. To address this gap in training, a simulator model for transcystic and transcholedochal LCBDE was developed and evaluated. METHODS: A procedure algorithm incorporating essential cognitive and technical steps of LCBDE was developed, along with a physical model to allow performance of a simulated procedure. Modified Objective Structured Assessment of Technical Skills (OSATS) rating scales were developed to assess performance on the model. Construct validity was assessed by comparing the performance of novices (residents and surgeons without LCBDE experience) versus experienced subjects (surgeons with previous LCBDE experience). Concurrent validity was assessed by comparing scores from the LCBDE scales to those from the standard OSATS scale. Internal consistency and interrater reliability were assessed by comparing performance scores assigned by three independent raters. RESULTS: Sixteen novices and five experienced subjects performed simulated procedures, with novices scoring lower than experienced subjects on both transcystic (20 ± 3 vs. 33 ± 2 [possible score range, 0-45], p < 0.001) and transcholedochal (25 ± 8 vs. 42 ± 3 [possible score range, 0-53], p < 0.001) rating scales. Scores on the rating scales correlated significantly with scores from the standard OSATS scale. Internal consistency and interrater reliability of the LCBDE rating scales were favorable. CONCLUSIONS: The LCBDE simulator is a low-cost yet realistic physical model that allows performance and evaluation of technical skills required for LCBDE. The LCBDE rating scales show evidence of construct validity, concurrent validity, internal consistency, and interrater reliability. Use of the LCBDE model and associated rating scales allows procedure-specific feedback for trainees and could be used to improve current training.

Development of a feasible transrectal natural orifice transluminal endoscopic surgery (NOTES®) approach in a cadaveric appendectomy model: anterior is better.

BACKGROUND: The transrectal natural orifice transluminal endoscopic surgery (NOTES) approach is a potentially promising alternative to transgastric or transvaginal approaches for intraperitoneal procedures. However, whether the optimal transrectal approach for intraperitoneal surgery is anterior or posterior remains unknown. To evaluate this, a prospective comparison of anterior and posterior transrectal NOTES approaches in a cadaveric appendectomy model was performed. METHODS: Operations were performed on human cadavers using a transanal endoscopic microsurgery (TEM) scope to assist with access and closure. Posterior access was achieved by tunneling cephalad through the retrorectal space into the peritoneal cavity. Anterior transrectal access was established through the rectal wall just above the peritoneal reflection. A dual-channel flexible endoscope was used to perform appendectomies. Rectotomies were closed using sutures or staples. Operative time, degree of laparoscopic assistance, complications, and leak-testing results were recorded. RESULTS: This study investigated 10 cadavers with access and closure attempted using both anterior (n = 10) and posterior (n = 5) approaches, whereas appendectomies were performed using either an anterior (n = 8) or a posterior (n = 2) approach. The anterior approach required less time than the posterior approach for peritoneal access (4 ± 1 vs. 61 ± 14 min; p < 0.001), specimen extraction (2 ± 1 vs. 5 ± 1 min; p < 0.01), and the total operation (99 ± 35 vs. 176 ± 26 min; p = 0.02). A "pure" NOTES dissection was possible with the anterior approach using rigid transanal instruments for assistance. Dissection time, closure time, and the incidence of complications were similar between the two approaches. Leak testing of closures showed significant variability for all closure types. CONCLUSION: Transrectal NOTES appendectomy is feasible in a cadaveric model using an anterior transrectal approach. This approach is technically easier, results in shorter operative times, and allows for a "pure" NOTES dissection compared with a posterior transrectal approach. Leak pressure testing of NOTES closures is unreliable in the cadaveric model.

Effect of training and instrument type on performance in single-incision laparoscopy: results of a randomized comparison using a surgical simulator.

PURPOSE: Single-incision laparoscopy (SIL) is potentially less invasive compared with standard laparoscopic surgery (LAP); however, it may be more technically challenging and have a longer learning curve. A two-phase study was conducted to examine the performance of standardized tasks on a surgical simulator by novices during a distributed training period. Phase 1 examined the effect of LAP-specific or SIL-specific training on skill acquisition for both techniques. Phase 2 compared the effectiveness and learning curves of additional instrument types for SIL (straight [STR] vs. dynamic articulating [D-ART]). METHODS: Medical students without previous surgical experience were randomized to LAP-specific training or SIL-specific training, using static articulating instruments [S-ART] for SIL. LAP and SIL scores on the peg transfer (PEG) and pattern cutting (CIRCLE) tasks from the Fundamentals of Laparoscopic Surgery (FLS) were measured at baseline and after four training sessions. In phase 2, a new group of subjects were randomized to SIL training using STR or D-ART instruments, with similar baseline and post-training testing. FLS task scores were calculated and compared according to training regimen and instrument type. RESULTS: Forty-five subjects completed the study. All scores improved significantly during the training period. Improvement in LAP score was similar between LAP-trained and SIL-trained groups. Improvement of SIL score was better for the SIL-trained group. Final scores were better and the learning curve was shorter for LAP versus SIL technique, with no differences in SIL scores according to instrument type. CONCLUSIONS: LAP technique results in superior task performance with a shorter learning curve compared with SIL technique during a standardized training period. SIL-specific simulator training is better than LAP training alone to improve SIL performance. Neither S-ART nor D-ART instruments for SIL are associated with improved performance or shorter learning curve compared with STR instruments.

Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review.

INTRODUCTION: The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data. METHODS: A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled. RESULTS: Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers. CONCLUSIONS: NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.

Natural orifice translumenal endoscopic surgery: progress in humans since white paper.

Since the first description of the concept of natural orifice translumenal endoscopic surgery (NOTES), a substantial number of clinical NOTES reports have appeared in the literature. This editorial reviews the available human data addressing research questions originally proposed by the white paper, including determining the optimal method of access for NOTES, developing safe methods of lumenal closure, suturing and anastomotic devices, advanced multitasking platforms, addressing the risk of infection, managing complications, addressing challenges with visualization, and training for NOTES procedures. An analysis of the literature reveals that so far transvaginal access and closure appear to be the most feasible techniques for NOTES, with a limited, but growing transgastric, transrectal, and transesophageal NOTES experience in humans. The theoretically increased risk of infection as a result of NOTES procedures has not been substantiated in transvaginal and transgastric procedures so far. Development of suturing and anastomotic devices and advanced platforms for NOTES has progressed slowly, with limited clinical data on their use so far. Data on the optimal management and incidence of intraoperative complications remain sparse, although possible factors contributing to complications are discussed. Finally, this editorial discusses the likely direction of future NOTES development and its possible role in clinical practice.

Preoperative ultrasound measurements predict the feasibility of gallbladder extraction during transgastric natural orifice translumenal endoscopic surgery cholecystectomy.

BACKGROUND: Extraction of a gallbladder through an endoscopic overtube during natural orifice translumenal endoscopic surgery (NOTES) transgastric cholecystectomy avoids potential injury to the esophagus. This study examined the rate of successful gallbladder specimen extraction through an overtube and hypothesized that preoperative ultrasound findings could predict successful specimen passage. METHODS: Gallbladder specimens from patients undergoing laparoscopic cholecystectomy were measured, and an attempt was made to pull the specimens through a commercially available overtube with an inner diameter of 16.7-mm. A radiologist blinded to the outcomes reviewed the available preoperative ultrasound measurements from these patients. Ultrasound dimensions including gallbladder length, width, and depth; wall thickness; common bile duct diameter; and size of the largest gallstone (LGS) were recorded. Multiple logistic regression analysis was performed to determine whether ultrasound findings and patient characteristics (age, body mass index [BMI], and sex) could predict the ability of a specimen to pass through the overtube. RESULTS: Of 57 patients, 44 (77%) who had preoperative ultrasounds available for electronic review were included in the final analysis. Gallstones were present in 35 (79%) of these 44 patients. Intraoperative gallbladder perforation occurred in 18 (41%) of the 44 patients, and 16 (36%) of the 44 gallbladders could be extracted through the overtube. Measurement of LGS was possible for 23 patients, and indeterminate gallstone size (IGS) was determined for 12 patients. The rate for passage of perforated versus intact gallbladders was similar (40% vs. 23%; p = 0.054). The LGS (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02-1.33; p = 0.021) and IGS (OR, 22.97; 95% CI, 1.99-265.63; p = 0.025) predicted failed passage on multivariate logistic regression analysis. The passage rate was 80% for LGS smaller than 10 mm or no stones present, 18% for LGS 10 mm or larger, and 8% for IGS (p < 0.001). CONCLUSION: A majority of cholecystectomy specimens cannot pass through an endoscopic overtube. Preoperative ultrasound findings can predict successful specimen extraction. An IGS or a gallstone 10 mm or larger should be considered a relative contraindication to transgastric NOTES cholecystectomy.

Single-incision laparoscopic surgery (SILS™) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator.

BACKGROUND: Single-incision laparoscopic surgery (SILS™) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS™ may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS™ technique. METHODS: Medical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILS™-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILS™, the subjects used an FLS box-trainer modified to accept a SILS Port™ with two working ports for instruments and one port for a 30° 5-mm laparoscope. SILS™ tasks were performed with instruments capable of unilateral articulation. SILS™ suturing was performed both with and without an articulating EndoStitch™ device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILS™ FLS score (SS), were calculated using standard time and accuracy metrics. RESULTS: There were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILS™ suturing using the articulating suturing device was superior to the use of a modified needle driver technique. CONCLUSIONS: SILS™ is more technically challenging than standard laparoscopic surgery. Using currently available SILS™ platforms and instruments, even surgeons with SILS™ experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILS™.