Goal-directed laparoscopic training leads to better laparoscopic skill acquisition.

INTRODUCTION: Laparoscopic skills training outside the operating room is becoming the standard for educating surgical residents. Because of the restrictions on the work week, it is imperative for this training to be efficient. We hypothesized that goal-directed laparoscopic training (GDLT) would result in better skill acquisition than laparoscopic training without goals (LT). METHODS: Second-year general surgery residents participated in this study. Metrics were scores that incorporated time and errors. One group of residents (LT) went through a 10- week laparoscopic training course without goals; one group of residents (GDLT) was given goals to achieve during their course. Each group practiced for the same amount of time. The tasks were peg exercise, run the rope, pattern cutting, clip/cut vessel, extracorporeal knot tying, intracorporeal knot tying, and suturing device. Statistical analysis was performed via 2-tailed Mann-Whitney tests. RESULTS: There were 8 residents in the LT group and 7 residents in the GDLT. The GDLT group had statistically significant higher scores on 7 of the 8 tasks compared the LT group (P < .02 to P < .0001). The GDLT group performed better in the final task, suturing device, than the LT group, but this did not reach statistical significance (451 vs 414; P = .14). CONCLUSIONS: GDLT should be used by surgeons instead of LT. Future studies need to examine whether GDLT translates into a better operative technique and outcomes.

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery.

INTRODUCTION: Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery can be challenging for the novice. One technique is the use of an optical viewing trocar without prior abdominal insufflation. This investigation tests the hypothesis that this technique can be taught to novice surgeons with good results. METHODS: Patients undergoing laparoscopic bariatric surgery were included. Novice surgeons (residents/fellows) with 0-50 initial trocar placements placed the initial trocar and insufflated the abdomen in the presence of an expert surgeon (>300 initial trocar placements in morbidly obese patients). Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as the time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). Novice times were compared with expert times. RESULTS: There were 81 patients (56 by expert and 25 by novice) in this study. No bowel or vessel injury during initial trocar placement was noted. No correlation was seen between times and BMI or waist/hip circumference (P = NS). Mean expert trocar placement time was shorter than the mean novice time (25 +/- 9 versus 54 +/- 27 s; P < 0.0001); although there was no difference in mean insufflation time (expert versus novice: 16 +/- 5 versus 19 +/- 10; P = NS). The mean total time to place the initial trocar and insufflate the abdomen for the novices was 72 +/- 26 s. CONCLUSIONS: Initial trocar placement can be taught safely to novices. The technique using an optical viewing trocar without prior abdominal insufflation is effective and efficient in morbidly obese patients.

Support group meeting attendance is associated with better weight loss.

BACKGROUND: Support group meetings (SGM) are assumed to be an integral part of success after bariatric surgery. This investigation studies the effect of SGM on weight loss as well as factors associated with attendance of SGM. It is our hypothesis that patients who attend SGM (ASGM) lose more weight than those patients who do not attend SGM (NASGM). METHODS: Postoperative bariatric patients completed a questionnaire regarding their opinions of SGM. Change in body mass index (BMI) was computed for each patient. The patients were then divided into two groups: ASGM and NASGM for data comparison. RESULTS: There were 46 patients in the investigation. Patients in the NASGM group tended to feel that SGM are not needed after bariatric surgery compared to the ASGM group (5.29 vs. 7.06; p = 0.07). Patients in the NASGM group tended to feel that they would lose the same amount of weight with or without attending SGM compared to the ASGM group (5.67 vs. 7.38; p = 0.07). There were no differences in distance to clinic nor in time to clinic between both groups. Gastric bypass patients in the ASGM group had a statistically significantly higher percent decrease in BMI than the patients in the NASGM group (42% vs. 32%; p < 0.03). CONCLUSION: Patients in the ASGM group lose more weight than patients in the NASGM group. The importance of attending SGM should be incorporated in preoperative patient counseling and encouraged during postoperative follow-up visits.

Postoperative laparoscopic bariatric surgery patients do not remember potential complications.

BACKGROUND: Despite comprehensive preoperative education, patients may forget important information such as potential complications. METHODS: Patients who had undergone laparoscopic bariatric surgery were surveyed. All patients were asked to write down as many as possible of the potential complications. Preoperatively, patients had been given an educational book, two preoperative educational appointments, a test, and an informed consent discussion and form with clear presentation of complications which may occur. RESULTS: There were 70 patients in this investigation (75% response rate), with 49 laparoscopic gastric bypass patients (bypass), 18 laparoscopic adjustable gastric banding patients (band), and 3 patients who did not indicate their procedure. Patients listed an average of 5.1 complications. Complications were grouped in 12 categories for each procedure. Percentages reported by patients (bypass vs band) were: Death 34 (69%) vs. 13 (72%), Injury to GI tract/leak 14 (29%) vs. 5 (28%), Conversion 1 (2%) vs 0 (0%), CV/pulmonary issues 11 (22%) vs. 4 (22%), Stenosis/ulcer 6 (12%) vs NA, Band erosion/migration NA vs 9 (50%), Malnutrition 24 (49%) vs, 4 (22%), GI symptoms 19 (39%) vs. 6 (33%), Infection 15 (31%) vs. 10 (56%), Weight regain/inadequate loss 5 (10%) vs. 3 (17%), Thromboembolic event 7 (14%) vs. 3 (17%), and Hemorrhage 8 (16%) vs. 0 (0%). CONCLUSIONS: Many patients forget some of the serious complications after laparoscopic bariatric surgery. This may have important medicolegal consequences especially during malpractice lawsuits. These data underscore the need for continual follow-up and education in this patient population.

Knowledge and opinions regarding Medicare reimbursement for laparoscopic cholecystectomy.

BACKGROUND: Medicare, via its fee schedule, determines amount of payment to physicians for services for its beneficiaries. Because many private insurance companies base their payment schedule on Medicare rates, it is important for physicians to know the rates of commonly performed procedures. In addition, it seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient, student, resident, and surgeon knowledge and opinion of Medicare reimbursements for laparoscopic cholecystectomy. METHODS: Patients, students, residents, and surgeons filled out an IRB-exempted survey. The survey included a written description of a laparoscopic cholecystectomy. All participants were asked to give their thoughts of what Medicare currently reimburses for a laparoscopic cholecystectomy ($622) and what they thought Medicare should reimburse for a laparoscopic cholecystectomy for our geographic area. RESULTS: There were 105 participants (47 patients, 17 medical students, 33 surgical residents, and 8 attending surgeons) in the investigation. The reported mean reimbursements of what each group thought Medicare pays were patients, $9,396; students, $3,077; residents, $800; and surgeons, $711. The reported mean reimbursements of what each group thought Medicare should pay were patients, $8,067; students, $3,971; residents, $1,444; and surgeons, $1,600. The mean reimbursements were statistically different between all groups in both the amount Medicare currently pays and the amount Medicare should pay. CONCLUSION: Most of our participants overestimated what Medicare currently pays for laparoscopic cholecystectomy. Even the mean amount reported in the attending surgeon group was greater than the actual payment. All groups felt Medicare should pay more than the current rate; however, only patients thought Medicare should pay less than they currently pay (probably because of the incorrect perception of the current fee schedule).

Band versus bypass: influence of an educational seminar and surgeon visit on patient preference.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are 2 common weight loss procedures. This investigation examined the effect of a preoperative educational seminar (ES) and surgeon visit (SV) on patients' choice of bariatric procedure. METHODS: In our practice, patients choose their procedure. New patients receive an overview of both procedures in an ES, including the risks and benefits, and then meet individually with a surgeon (SV) to answer any additional questions. Three identical surveys (before the ES, after the ES, and after the SV) were given to new patients who voluntarily participated in this study. The survey queried procedure choice and influencing factors. RESULTS: A total of 47 patients participated. Of these 47 patients, 31 had researched the procedures before the ES and 13 were unsure of the differences between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding before the ES, 4 were after the ES, and 1 was after the SV. Also, 11% of patients changed their procedure choice as a result of attending the ES and SV; 15%, 13%, and 13% of patients were willing to be randomized to either procedure before the ES, after the ES, and after the SV, respectively. CONCLUSIONS: Only 11% of patients changed their procedure choice as a result of attending the ES and SV. Thus, patient decisions are usually made before meeting the surgeon, and the information provided at the ES and SV simply reinforced those decisions. Only 13% of patients were willing (4% very willing and 9% somewhat willing) to be randomized to either procedure (laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding). It is likely that patients had confidence in, and were comfortable with, 1 procedure over the other, and therefore were unwilling to undergo the other procedure.

Laparoscopic re-operations for band removal after open banded gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) has been demonstrated to be an effective treatment for weight loss in the morbidly obese. Numerous variations of the RYGBP have been performed, including placing a ring proximal to the gastric outlet. This ring in RYGBP is intended to decrease pouch dilation and limit weight regain. We reviewed our experience in laparoscopic re-operation after open banded RYGBP. METHODS: All charts of patients who underwent laparoscopic revisional bariatric surgery were reviewed. Patients who had laparoscopic removal of the band following the open banded RYGBP were reviewed in this study. RESULTS: There were 4 patients who had laparoscopic removal of the band. The indication in all patients was dysphagia and emesis. The ring removed was a silicone band (1) and a large braided non-absorbable suture (3). After the laparoscopic reoperation, there was immediate relief. There has been an average of 5.8 kg weight regain at average follow-up of 30 months. CONCLUSIONS: This complication after open banded RYGBP may require operative intervention. Laparoscopic removal of a band is feasible and safe.