Vein harvest: minimally invasive techniques and reduction in complications.

Revascularization of the coronary or lower extremity circulation ideally requires an autologous conduit. The saphenous vein is the most commonly used graft. Minimally invasive surgical techniques for harvesting of the greater saphenous vein (GSV) are gaining popularity. With better instruments, critical evaluation of techniques and longer follow-up of patients, the outcome of such vein harvesting is improving. An increasing number of authors are reporting a variety of techniques with reduction in wound complications compared to conventional surgery.

Progression of gastric mucosal dysplasia of the postgastrectomy stomach.

Gastric cancer, if diagnosed at the symptomatic stage, has a poor prognosis, with an overall 5 year survival of about 5%. The surgical treatment of early gastric cancer increases this 5-year survival rate to 90%. In Japan, endoscopic surveillance has increased the proportion of gastric cancer detected at an early stage from 15% in 1960 to 50% in 1985, and the overall 5 year survival has been increased from 35% to 70%. Mass screening in Japan is worthwhile because the incidence of gastric cancer is about 80 cases per 100,000 population per annum (age standardized). But in other countries where the incidence is much lower the case for mass screening is weak and selective screening of those at high risk is advocated.

Port-site metastasis in the abdominal wall: fact or fiction?

Port-site metastasis (PSM) following minimally invasive surgery (MIS) is discussed and four points are addressed: 1) the occurrence of PSM; 2) the occurrence of PSM as part of distant metastasis, and the need for more studies to confirm that it can occur purely as implantation metastasis; 3) the preliminary experimental evidence suggesting that carbon dioxide might have a role in PSM and that viable cells can be dispersed by pneumoperitoneum (with more experimental work and clinical studies needed to confirm these observations); and 4) some studies showing an increased incidence of PSM after MIS compared with open surgery. Prospective randomized studies with adequate follow-up are needed to establish the validity of such reports.

Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons.

BACKGROUND: Laparoscopic surgery adapts poorly to apprenticeship models for general surgical training. Standardized skill acquisition and validation programs, targeted performance goals, and a supervised, enforced, skill-based curriculum that readily can be shared between trainee and instructor must replace the observation and incremental skill-acquisition model used in an open surgical environment. The Yale Laparoscopic Skills and Suturing Program was used to develop a data bank for objective evaluation of dexterity and suturing skills for laparoscopic surgical training. The current study compares trainee and senior surgeon performance in this standardized training program. OBJECTIVE: To compare objectively evaluated laparoscopic surgical skills and suturing capability of senior surgeons and of residents after they have completed the same standardized training regimen. METHODS: Two hundred ninety-one trained surgeons performed 8730 standardized laparoscopic dexterity drills and 2910 intracorporeal suturing exercises in the Yale Laparoscopic Skills and Suturing Program. Their performance was supervised by an instructor who recorded performance and timing of the tasks in a 2 1/2-day program. Ninety-nine residents performed the same drills and exercises the same number of times and followed the same technique for intracorporeal suturing. Percentile graphs were prepared for each type of drill and suturing exercise to allow comparison of levels of achievement among different training groups. RESULTS: The performance of the residents was the same as that of trained surgeons for the rope pass drill and the suturing exercise. Residents in comparison with trained surgeons performed the triangle transfer drill faster and the new cup drop drill and old cup drop drill more slowly. There was no significant difference in performance between male and female residents. CONCLUSION: Basic skills relevant to laparoscopic performance can be acquired with a high level of competence in a brief course unrelated to prior surgical experience, sex, or age.

Telementoring. A practical option in surgical training.

BACKGROUND: Telemedicine offers significant advantages in bringing consulting support to distant colleagues. There is a shortage of surgeons trained in performing advanced laparoscopic operations. AIM: Our aim was to evaluate the role of telementoring in the training of advanced laparoscopic surgical procedures. METHODS: Student surgeons received a uniform training format to enhance their laparoscopic skills and intracorporeal suturing techniques and specific procedural training in laparoscopic colonic resections and Nissen fundoplication. Subsequently, operating rooms were equipped with three cameras. Telestrator (teleguidance device), instant replay (to critique errors), and CD-ROM programs (to provide information of reference) were used as intraoperative educational assistance tools. In phase I, four colonic resections were performed with the mentor in the operating room (group A) and four colonic resections were performed with the mentor on the hospital grounds, but not in the operating room (group B). The voice and video signals were received at the mentor's location, using coaxial cable. In phase II, two Nissen fundoplications were performed with the mentors in the operating room (group C) and two Nissen fundoplications were performed with the mentors positioned five miles away from the operating room (group D), using currently existing land lines at the T-1 level. RESULTS: There were no differences in the performances of the surgeons and outcome of the operations between groups A & B and C & D. It was possible to tackle the intraoperative problems effectively. CONCLUSIONS: The telementoring concept is potentially a safe and cost-effective option for advanced training in laparoscopic operations. Further investigation is necessary before routine transcontinental patient applications are attempted.

Skill acquisition and assessment for laparoscopic surgery.

OBJECTIVES: To describe a training method with objective evaluation to enhance laparoscopic surgical skills to provide training in laparoscopic suturing techniques and to assess whether specific training exercises were helpful in the attainment of intracorporeal suturing skills. DESIGN: Trainees (N = 150) were asked to perform standardized drills with distinct mechanical features, and skill acquisition was determined by accuracy and timing. Trainees were tested for the ability to perform an intracorporeal laparoscopic suture before and after analogous skill training with the drills. SETTING: The training courses were held in teaching and nonteaching hospitals. PARTICIPANTS: Board-certified or board-eligible surgeons. MAIN OUTCOME MEASURES: Supervision by trained instructors and documentation of the time required to perform standardized drills. RESULTS: The trainees showed steady improvement in skill acquisition during 10 trials (P < .001). Significant (P < .001) improvement was noted for the performance of suturing after compared with before the drills. CONCLUSION: Three standardized laparoscopic drills have been tested in 150 trainees and demonstrate the incremental acquisition of skills that correlate with improved performance in a challenging and complex laparoscopic skill, intracorporeal suturing.

Complications of laparoscopic inguinal hernia repair.

Laparoscopic herniorrhaphy has been gaining popularity along with other minimally invasive surgical techniques. With the sophistication of instruments, evaluation of techniques and longer follow-up of patients, the outcome of such repairs is changing. Many authors are reporting a variety of techniques, complications, and results compared to conventional surgery.

Economic considerations in laparoscopic surgery: disposable versus reusable instrumentation.

The subject of the economic considerations involved in using disposable versus reusable instrumentation has become a controversial issue.The economic evaluations performed purely by economists may not ap- peal to the surgeon and may not be applicable in different parts of the world. The quality of disposable instruments and their convenience in laparoscop'ic surgery is not at issue; the controversy, instead, centers on the question of the cost-effectiveness of disposable equipment. High-quality instruments enable safe, sue- cessful operations.' Some instruments are not available in reusable form and the quality of some reusable in- struments (e-g-, laparoscopic scissors) is sometimes questionable, particularly as they are periodically in need of servicing or repair. For a routine cholecystectomy, clips can be mounted on a reusable applier to ligate the cystic duct and artery. This can save considerable cost. However, disposable clips and their appliers should be available in the operating room (OR) in case of emergencies such as uncontrolled bleeding.

The clinical anatomy of undescended testis and varicocele for laparoscopic management.

Undescended testis or cryptorchidism remains a common condition. It affects 1% of individuals! and is treated by pediatric surgeons, urologists, and general surgeons depending on the age of the patient, spe- cialist services, and expertise available. Laparoscopy has been used for the localization of impalpable testis for more than 15years. However, minimal access surgery has now made its impact in this field of surgery in terms of surgical intervention. It is used not only for the localization of undescended testis but also to per- form Iaparosco'pic orchidectomy/ and both stages of the Foweler-Stevens orchiopexyY Minimal access surgery is also used for the ligation of the testicular vein for var-icocele.' The clinical anatomy of the unde- scended testis and varicocele is interrelated and therefore is dealt with in the same chapter, although there is no association between the two clinical conditions.

Port-site metastasis: tip of the iceberg?

In 1870 Reincke reported two cases in which tumors developed at the sites of paracentesis for ascites due to peritoneal carcinomatosis. History was repeated in a different context when two cases of port-site metastasis were reported in 1993. In the last 200 years tumor spread has remained a difficult phenomenon to understand, and minimal access surgery has added several more questions. Port-site metastasis has gained the attention of not only minimally invasive surgeons but also the media. Performing an operation for a benign condition is quite different from performing one for a malignant condition. Patients suffering from the latter may not value the advantages of minimal access surgery if there is an increased risk of tumor spread and less of a likelihood for cure.

Thermodynamic effects of bile acids in the stomach.

The surface thermodynamic effects of bile acids in the stomach were assessed in 48 subjects who had undergone gastric surgery for peptic ulcer disease and in 52 controls with medically healed ulcers. We derived values for surface tension of gastric mucosa from contact angle using a goniometer and measured the surface tension of gastric juice by the drop-weight method. Subjects with gastric surgery had higher median fasting bile acid concentrations than controls (1.2 vs. 0.1 mmol/L; P less than 0.0001), higher mean mucosal surface tension (51.9 vs. 47.9 mN/m; P less than 0.0001), and lower mean surface tension of gastric juice (43.2 vs. 51.7 mN/m; P less than 0.0001). Subjects who had had a Billroth II gastrectomy (n = 19) had higher bile acid concentrations (5.8 vs. 0.6 mmol/L; P less than 0.01), higher mucosal surface tension (53.7 vs. 50.3 mN/m; P less than 0.05), and lower gastric juice surface tension (41.3 vs. 47.1 mN/m; P less than 0.05) than those who had a vagotomy and drainage procedure (n = 17). Overall, intragastric bile acid concentration correlated directly with surface tension of gastric mucosa (r = 0.51, P less than 0.0001) and inversely with that of gastric juice (r = -0.60, P less than 0.0001). In conclusion, the interfacial energy barrier at the surface of the gastric mucosa is overcome in the presence of intragastric bile acids.

Relation between severity and extent of precancerous lesions in the postoperative stomach.

The relation between the severity and extent of precancerous lesions in a precancerous condition of the stomach was assessed, to find a means of reducing the endoscopic workload required for the detection of such lesions. 87 subjects who had had gastric surgery for peptic ulcer more than 20 years ago underwent gastric endoscopy and biopsy. Severity of dysplasia correlated with its extent. Severity of intestinal metaplasia correlated with its extent and with severity of dysplasia. Type of operation, but not sex or type of ulcer, was the factor most strongly associated with dysplasia. Previous Billroth II operations were more strongly associated with occurrence of dysplasia (85%) than were other operations. In patients with previous Billroth II operations, moderate and severe dysplasia were commoner around the stoma (37%) than in the body (10%). These findings indicate that there is a relation between the severity and extent of precancerous lesions, which suggests that patients with dysplasia have widespread gastric mucosal instability. They also indicate that, if endoscopic screening is limited to Bilroth II subjects and if biopsies are limited to the stoma, endoscopic workload can be reduced by 85%, with only a small reduction (15%) in detection of moderate and severe dysplasia.