Factors influencing surgical performance and learning progress in minimally invasive surgery - results of an interdisciplinary multicenter study.

BACKGROUND: Advancing surgical techniques require a high level of adaptation and learning skills on the part of surgeons. The authors need selection procedures and decision support systems for the recruitment of medical students and young surgeons. The authors aimed to investigate factors influencing the surgical performance and learning abilities of surgeons and medical students. MATERIALS AND METHODS: The training scores of persons attending 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, individual characteristics, and the results of psychomotor tests of three-dimensional imagination and hand-eye coordination were correlated. Similar analyses were performed for medical students in their final clinical year from 2019 to 2020. The training concept was evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: In all, 180 of 206 physicians (response rate 87.4%) and 261 medical students (response rate 100%) completed the multistage training concept successfully. Of personal characteristics, the strongest correlation was noted for good surgical performance and learning success, and the absolute number of performed laparoscopic surgeries ( r =0.28-0.45, P <0.001/ r =0.1-0.28, P <0.05). A high score on the spatial visualization ability test was also correlated with good surgical performance ( r =0.18-0.27, P <0.01). Among medical students with no surgical experience, however, age was negatively correlated with surgical performance, that is the higher the age, the lower the surgical performance ( r =0.13/ r =0.22, P <0.05/ P <0.001). CONCLUSION: Individual factors (e.g. surgical experience, self-assessment, spatial visualization ability, eye-hand coordination, age) influence surgical performance and learning. Further research will be needed to create better decision support systems and selection procedures for prospective physicians. The possibilities of surgical training should be improved, promoted, and made accessible to a maximum number of surgical trainees because individual learning curves can be overcome even by less talented surgeons. Training options should be institutionalized for those attending medical school.

The pelvitrainer for training in laparoscopic surgery - A prospective, multicenter, interdisciplinary study: Experimental research.

BACKGROUND: Minimally invasive surgical procedures have a flat learning curve, especially in the initial period of a surgeon's training. Pelvitrainers enable the prospective surgeon to drill the surgical technique, including camera navigation, instrument manipulation, and the individual steps of the operation, on a model rather than a patient. Integrating the pelvitrainer into standardized surgical training programs is challenging, but would be essential to achieve optimum effects of long duration in surgical education. MATERIAL AND METHODS: The pelvitrainer Realsimulator 2.0 (Endodevelop) was evaluated in 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, The training concept was implemented and evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: One hundred and eighty of 206 physicians (response rate 87.4%) completed the multi-stage training concept successfully. A significant (p < 0.001) objective improvement (positive learning curve) was observed for all exercises on the pelvitrainer. The trainer's subjective evaluation revealed positive ratings for design (median 82%, IQR 71-91%), camera navigation (87%, IQR 76-95%), and instrument manipulation (median 87%, IQR 77-94%). A follow-up survey performed six months after the course confirmed its sustainable and high benefits in clinical routine (median 82%, IQR 70-97%). CONCLUSION: The present investigation proved the high educational value of pelvitrainers, which can be enhanced by using a structured training concept. The benefit of training courses for health care justifies their incorporation into a standardized training curriculum. The completion of such training courses should be regarded as a prerequisite for a doctor to qualify as an independent surgeon.

The influence of persistent bleeding after supracervical hysterectomy on depressive and anxious symptoms: a prospective bicenter study.

PURPOSE: Postoperative spotting is a frequent adverse symptom after laparoscopic supracervical hysterectomy (LSH). The conical excision (eLSH) reduces the postoperative spotting rate, but data in a larger collective are still rare and inconsistent. The influence of persistent bleeding on the anxious and depressive symptoms has not been analyzed yet. METHODS: 311 patients, who underwent a laparoscopic supracervical hysterectomy with conical excision (n = 163), or with straight cervical resection (n = 148) were included. Anxious and depressive symptoms and postoperative spotting were recorded before operation, at 3 month follow-up and at 1 year follow-up in both operative groups using a validated questionnaire (German version of Hospital Anxiety and Depression Scale, HADS-D) and additional questions concerning the frequency and impact of bleeding. Statistical analysis included the impairment of bleeding as well as its impact on depressive and anxious symptoms for both groups. RESULTS: 11.5% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves depressive and anxious symptoms at 3 and at 12 month follow-up for both groups (p < 0.001) independent on residual spotting. Patients with a preoperative continuous bleeding showed a maximum benefit independent on operative method. CONCLUSION: Laparoscopic supracervical hysterectomy has a positive effect on anxious and depressive symptoms in the short-term and intermediate-term follow-up. The conical excision of the cervical stump reduces postoperative spotting rate, but has no explicit advantage on symptoms of depression or anxiety, irrespective of residual postoperative spotting.

Laparoscopic versus vaginal native tissue repair in combination with pectopexy. Sub-analysis from an international, prospective, and multi-centre study: short term results.

INTRODUCTION: The use of mesh for vaginal repairs is currently problematic and as a consequence, there is increased interest in native tissue repair. We describe the follow-up data of a sub-analysis of a prospective and multi-center study focusing on the combination of pectopexy and native tissue repair. Patients were followed up for 12-18 months after surgery (+ SD: 15). Two-hundred and sixty-four patients attended the clinics for physical examination and were integrated into the follow-up. Cystocele repair was performed laparoscopically in 84 patients and vaginally in 52 patients. Posterior repair was performed vaginally in 40 patients and laparoscopically in 53 patients. RESULTS: Clinical success rate, patient recommendations and patient satisfaction rates were similar in both groups. The laparoscopic anterior repair resulted in an 89% cure or anatomical improvement rate; this compared to 94.2% for the vaginal approach. In the posterior group, laparoscopy resulted in a 94.3% cure or improvement rate compared to 97.5% in the second group. CONCLUSIONS: The outcomes of both strategies showed satisfactory results in our study. Consequently, surgeons may choose between the two strategies according to their preference and skill. The two approaches only differed with regard to vaginal scarring. We suggest future research investigating the long-term impact of scarring.

Significant improvement of laparoscopic knotting time in medical students through manual training with potential cost savings in laparoscopy - an observational study

Objective: Laparoscopy is a standard procedure in operative gynaecology, but laparoscopic simulator training for novices/junior surgeons is not currently well-established. The aims of this study were to demonstrate that a laparoscopic knot course for trainees can significantly shorten the knotting time and to perform a counter-value calculation for the clinic's costs. Material and Methods: An observational study was performed with exercises on a laparoscopic box trainer as part of the practical clerkship in gynaecology and obstetrics between 07.10.2019-31.01.2020. At the beginning and at the end of the exercises, the participants made a laparoscopic knot and the difference in knotting time, Δt in seconds (s) was measured. Results: Eighty-eight medical students needed an average of 247.1 s for the first laparoscopic knot at the beginning of the course and an average of 45.43 s for the second at the end of the course. Mean shortening of the knotting time was 201.67 s or 81.6% (p=0.02). Calculating costs of an average of €40-50 for an operation minute would mean a cost saving of at least €120-150 for a partial node. Conclusion: Trainees can significantly improve their operative skills in a short time with the aid of surgical simulation training. Such training can be beneficial for clinics by reducing the operating time if the basics, such as sewing and instrument guidance, are learned on a simulator. We therefore suggest that operative simulation training should be mandatory in medical education.

Influence of androgen levels on conception probability in patients undergoing fertility treatment: a retrospective cohort study.

PURPOSE: Primary and secondary sterility have become an issue of increasing importance due to demographic and social changes in society. Data regarding the association between female androgen levels and the probability of successful conception after fertility treatment are sparse and contradictive. This study was designed to assess this clinical question. METHODS: In this retrospective single-center cohort study concentrations of androgens androstenedione, dehydroepiandrosteronsulfat (DHEAS) and testosterone (ng/ml) were investigated in the serum of patients presenting for sterility at the department of reproductive medicine of Saarland University hospital Homburg between January 2015 and December 2017. Androgen levels were correlated with reproductive outcomes. Statistical analysis was performed with the aid of SPSS version 24. Significance for conception rates in dependence of androgen concentration was assessed using Kruskal-Wallis test (significance was estimated with p < 0.05). RESULTS: The laboratory values of a total of 301 patients were examined (64% primary, 36% secondary sterility). Median age at first visit at the fertility department was 32.7 years (range 20-47 years). 64 pregnancies were observed during the study period (conception rate 21.3%). 23 out of 301 patients (7.6%) suffered from hypoandrogenaemia, 248 (82.4%) had normal androgen levels and 30 (10%) showed hyperandrogenaemia (p = 0.25). Regarding patients in whom fertility treatment was successful 3 (4.7%) showed hypoandrogenaemia, 54 (84.4%) were normoandrogenaemic and 7 (10.9%) had hyperandrogenaemia (p = 0.40 Kruskal-Wallis test). CONCLUSIONS: We found no association between female androgen levels and sterility and reproductive outcomes.

Value of clinical and laboratory inflammation factors in the postoperative period after laparoscopic urogynecological surgery.

BACKGROUND/AIMS: Leukocytes and C-reactive protein (CRP) levels are often used to detect infections. The aim of this study was to evaluate the diagnostic and screening validity of leukocytes and CRP levels as well as body temperature >38° C to predict infections after laparoscopic sacrocolpopexy. METHODS: The study included 287 patients suffering from genital prolapse higher than POP-Q I. In addition to the sacrocolpopexy, a laparoscopic supracervical hysterectomy was performed in cases of preexisting uterus (n = 171). Leukocytes and CRP levels were analyzed preoperatively and 4 days after surgery. Early and late onset of infections was documented. RESULTS: Urinary tract infection was identified as the most frequent early postoperative complication (11.4%). Early wound infections were found in 2.8% of the patients (8/287). Late onset of infections was found in 1% of patients (3/287). Areas under ROC curves were low for both leukocytes (0.52, 95% CI: 0.37-0.66) and CRP levels (0.60, 95% CI: 0.44-0.77). CONCLUSION: Our findings question the benefit of routine determination of leukocytes and CRP levels 4 days after surgery. The sensitivity and specificity of leukocytes and CRP levels are probably more significant after normalization of the initial tissue response (days 8-10).

Pain medication requirements after sacropexy and combination interventions.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery is associated with reduced morbidity, and postoperative pain is reduced. The aim of this study was to assess postoperative pain intensity, analgesic requirements, and the influence of cofactors after laparoscopic sacral colpopexy. METHODS: The study assessed 287 patients treated with laparoscopic sacropexy for genital prolapse with a Pelvic Organ Prolapse Quantification grade>1. Patients were asked to evaluate their pain postoperatively using a 4-point verbal pain rating scale. In addition, medical records were analyzed regarding the requirement for analgesic medication. RESULTS: Patients distinguished between abdominal pain and shoulder pain after laparoscopy. Abdominal pain reached maximum severity on day 1 and showed a good response to nonsteroidal antiphlogistics, whereas shoulder pain was rarely found (6.27%). Of the patients, 38% required no pain treatment or required 1 dose at most. The need for pain medication reached its climax on day 1 and decreased during the 5 following days. Non-opioid analgesics provided a sufficient therapeutic effect. CONCLUSION: Laparoscopic sacropexy is associated with a moderate degree of postoperative pain. Non-opioid analgesics should be preferred as first-line therapy. The typical shoulder-tip pain showed only a low prevalence in our study group. From our point of view, the low rate of shoulder-tip pain corresponded with the low intra-abdominal carbon dioxide pressure.