The use of a porcine model to teach advanced abdominal wall dissection techniques.

BACKGROUND: In the era of minimally invasive surgery, it is clear that a robust simulation model is required for the training of surgeons in advanced abdominal wall reconstruction. The purpose of this experimentation was to evaluate whether a porcine model could be used to teach advanced minimally invasive abdominal wall dissection techniques to novice surgeons. Secondary objectives included: time to completion, identification of various anatomical landmarks, to note the difference in porcine and human models and finally, the ability to dock a Da Vinci Xi robotic platform on the porcine model. METHODOLOGY: Two post-fellowship surgeons were given the task of performing an extended total extraperitoneal dissection (ETEP) on one female Landrace pig under the supervision of a surgeon experienced in robotic-assisted ventral hernia repair. This included insertion of ports, developing a retro-rectus plane, crossover from left to right rectus, bilateral transverse abdominus release, and sub-diaphragmatic dissection. A 5-mm vessel sealer was used to facilitate the dissection. The steps of the surgery were given to the trainees, and an experienced hernia surgeon guided the steps of dissection. The emphasis of the tasks was to develop the planes of extraperitoneal dissection to demonstrate that the porcine model could be considered for a viable and realistic model for training. RESULTS: The candidates were able to successfully complete the task and dock a Da Vinci Xi with the porcine model providing a realistic platform for training. CONCLUSION: The porcine model can be a considerable tool in the education of surgeons embarking on learning the art of minimally invasive abdominal wall reconstruction techniques. The advantage of live tissue dissection, similarity in anatomy and the relatively inexpensive availability of porcine models, makes it an unparalleled form of simulation-based training. We believe that this will have transitional capabilities to robotic ETEP education for complex hernia repair.

Does surgeon sex and anthropometry matter for tool usability in traditional laparoscopic surgery? A systematic review and meta-analysis.

INTRODUCTION: Hand size, strength, and stature all impact a surgeon's ability to perform Traditional Laparoscopic Surgery (TLS) comfortably and effectively. This is due to limitations in instrument and operating room design. This article aims to review performance, pain, and tool usability data based on biological sex and anthropometry. METHODS: PubMed, Embase, and Cochrane databases were searched in May 2023. Retrieved articles were screened based on whether a full-text, English article was available in which original results were stratified by biological sex or physical proportions. Article quality was discussed using the Mixed Methods Appraisal Tool (MMAT). Data were summarized in three main themes: task performance, physical discomfort, and tool usability and fit. Task completion times, pain prevalence, and grip style results between male and female surgeons formed three meta-analyses. RESULTS: A total of 1354 articles were sourced, and 54 were deemed suitable for inclusion. The collated results showed that female participants, predominantly novices, took 2.6-30.1 s longer to perform standardized laparoscopic tasks. Female surgeons reported pain at double the frequency of their male colleagues. Female surgeons and those with a smaller glove size were consistently more likely to report difficulty and require modified (potentially suboptimal) grip techniques with standard laparoscopic tools. CONCLUSIONS: The pain and stress reported by female or small-handed surgeons when using laparoscopic tools demonstrates the need for currently available instrument handles, including robotic hand controls, to become more size-inclusive. However, this study is limited by reporting bias and inconsistencies; furthermore, most data was collected in a simulated environment. Additional research into how anthropometric tool design impacts the live operating performance of experienced female surgeons would further inform this area of investigation.

Mesh versus non-mesh repair of groin hernias: a rapid review.

BACKGROUND: Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes. METHODS: Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool. RESULTS: The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain. CONCLUSIONS: Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

Validation of 3-Space Wireless Inertial Measurement Units Using an Industrial Robot.

Inertial Measurement Units (IMUs) are beneficial for motion tracking as, in contrast to most optical motion capture systems, IMU systems do not require a dedicated lab. However, IMUs are affected by electromagnetic noise and may exhibit drift over time; it is therefore common practice to compare their performance to another system of high accuracy before use. The 3-Space IMUs have only been validated in two previous studies with limited testing protocols. This study utilized an IRB 2600 industrial robot to evaluate the performance of the IMUs for the three sensor fusion methods provided in the 3-Space software. Testing consisted of programmed motion sequences including 360° rotations and linear translations of 800 mm in opposite directions for each axis at three different velocities, as well as static trials. The magnetometer was disabled to assess the accuracy of the IMUs in an environment containing electromagnetic noise. The Root-Mean-Square Error (RMSE) of the sensor orientation ranged between 0.2° and 12.5° across trials; average drift was 0.4°. The performance of the three filters was determined to be comparable. This study demonstrates that the 3-Space sensors may be utilized in an environment containing metal or electromagnetic noise with a RMSE below 10° in most cases.

Self-reported prevalence of injury and discomfort experienced by surgeons performing traditional and robot-assisted laparoscopic surgery: a meta-analysis demonstrating the value of RALS for surgeons.

BACKGROUND: The negative impact of traditional laparoscopic surgery (TLS) on surgeons has been well-established. Prevalence rates of discomfort and injury between 73% and 90% are regularly cited to support this, with robot-assisted laparoscopic surgery (RALS) often being presented as the solution. The purpose of this study was to systematically review pain studies of TLS and RALS surgeons, to consider the difference in the reported strain in general and concerning specific sites of the body. METHODS: PubMed, Embase, and Cochrane databases were searched in October 2019. The resulting articles were screened to ensure the full text was available in English, original data were presented, the study contained pain statistics for TLS or RALS, and the study had a long-term rather than an intra-operative focus. Quality was assessed using the SUrvey Reporting GuidelinE (SURGE). Results from studies were analyzed in two stages for TLS and RALS according to each anatomic region. RESULTS: A total of 1354 papers were found, from which 28 papers were chosen for inclusion. The average quality score of the included articles was 14.8. The risk ratio of experiencing symptoms related to TLS in comparison to RALS was 1.29; however, this was not significant. Discomfort was significantly more likely to be experienced in the back, elbows, and wrists/hands for those practicing TLS in comparison with RALS. The regions associated with the highest risk of injury for TLS and RALS were the back and neck, respectively. CONCLUSIONS: There is limited evidence in this study for the possibility that RALS is ergonomically more beneficial for the surgeon in comparison with TLS. Further analysis would be improved with the publication of larger, high-quality, homogenous studies, especially concerning injuries experienced by RALS surgeons, to overcome the limitations of heterogeneity and bias.

Muscle activation during traditional laparoscopic surgery compared with robot-assisted laparoscopic surgery: a meta-analysis.

BACKGROUND: The repetitive and forceful motions used by operating surgeons increase the risk of developing musculoskeletal disorders. Most ergonomists consider the surgical environment to be incredibly harsh for its workers. Traditional Laparoscopic Surgery (TLS) in particular has a number of physical and mental challenges associated with it, and while Robotic-Assisted Laparoscopic Surgery (RALS) provides several features that improve upon TLS, some surgeons have still reported musculoskeletal symptoms they attribute to RALS. In this paper, we endeavored to systematically review muscle activation for both TLS and RALS, to compare the modalities and present the results as a meta-analysis. METHODS: A literature search was conducted using Pubmed, Embase, and Cochrane databases in November 2018 with the following inclusion criteria: full text was available in English, the paper contained original data, EMG was one of the primary measurement techniques, and the paper included EMG data for both TLS and RALS. Results from studies were compared using standardized mean difference analysis. RESULTS: A total of 379 papers were found, and through screening ten were selected for inclusion. Sample populations ranged from 1 to 31 surgeons, and a variety of study designs and metrics were used between studies. The biceps were the only muscle group that consistently and significantly demonstrated lower muscle activation for RALS for all included studies. CONCLUSIONS: The results may support the belief that RALS is ergonomically superior to TLS, shown through generally lower muscle activation scores. However, these results must be interpreted with caution due to the heterogeneity between the studies and multiple potential sources for bias within studies. This analysis would be strengthened with a higher number of homogenous, high-quality studies examining larger sample sizes.

Thoracic sympathectomy: a review of current indications.

BACKGROUND: Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice. METHODS: The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required. RESULTS AND CONCLUSIONS: Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Thoracic sympathetic nerve reconstruction for compensatory hyperhidrosis: the Melbourne technique.

BACKGROUND: Compensatory hyperhidrosis (CH) is a potential complication following endoscopic thoracic sympathectomy (ETS) in the management of primary hyperhidrosis. CH is considered a permanent condition with significant psychosocial impacts but with few treatment options. Various reversal surgical techniques, aimed at reconstituting sympathetic pathways, have been developed but results have been inconsistent. OBJECTIVE: We present two case reports of a novel technique of reversal surgery, the Melbourne technique, which was employed to treat severe CH that developed within 3-5 months following ETS. Both patients were followed-up to 8 years. METHODS: The Melbourne technique employs an endoscopic approach to expose previously sympathectomized or sympathotomized thoracic sympathetic chains. In these two cases it was performed on the right side only. Instead of an interpositional nerve graft, an autogenous vein graft was simultaneously harvested and used as a nerve conduit to bridge the secondary nerve defect after neuroma excision. Long-term outcomes were assessed using the dermatology life quality index (DLQI) and the quality of life (QoL) questionnaires, which are validated for hyperhidrosis. RESULTS: In both cases, patients reported postoperative improvements in QoL scores. However, the improvement was more marked in one case compared with the other. There were no significant immediate and long-term postoperative complications. CONCLUSIONS: The Melbourne technique shows promise as an alternative to interpositional nerve grafts or nerve transfers employed in other endoscopic reversal surgeries for CH.

Sympathetic activity and markers of cardiovascular risk in nondiabetic severely obese patients: the effect of the initial 10% weight loss.

BACKGROUND: Obesity is associated with elevated cardiovascular mortality, which may be attributed, in part, to sympathetic nervous system (SNS) activation and an associated poor metabolic profile. We examined the effects of laparoscopic adjustable gastric band (LAGB) on SNS activity and cardiovascular profile when the initial weight loss of 10%, corresponding to the recommendation of clinical guidelines, was reached. METHODS: Direct muscle sympathetic nerve activity (MSNA, microneurography), baroreflex function, and cardiovascular profile were examined before and after a predetermined weight loss of 10% in 23 severely obese nondiabetic individuals. RESULTS: The 10% weight loss was achieved at an average of 7.3 ± 1.4 months (range = 1.3-23.3 months). This was associated with significant improvement in office systolic and diastolic blood pressure (BP) (-12 mm Hg and -5 mm Hg, respectively), a decrease in MSNA (33 ± 3 to 22 ± 3 bursts per minute), improvement in cardiac (16 ± 3 to 31 ± 4 ms/mm Hg) and sympathetic (-2.23 ± 0.39 to -4.30 ± 0.96 bursts/100 heartbeats/mm Hg) baroreflex function, total cholesterol (5.33 ± 0.13 to 4.97 ± 0.16 mmol/L), fasting insulin (29.3 ± 2.4 to 19.6 ± 1.1 mmol/L), and creatinine clearance (172 ± 11 to 142 ± 8 ml/min). None of the cardiovascular risk improvement related to the rate of weight loss. The change in systolic and diastolic BP correlated with change in waist circumference (r = 0.46, P = 0.04; r = 0.50, P = 0.02, respectively). CONCLUSIONS: The initial 10% weight loss induced by LAGB was associated with substantial hemodynamic, metabolic, SNS, and renal function improvements. Changes in waist circumference appear to be an important factor contributing to BP adaptation after LAGB surgery.

Solid versus liquid-satiety study in well-adjusted lap-band patients.

BACKGROUND: Patients following laparoscopic adjustable gastric banding (LAGB) are generally advised to avoid liquid calories, opt for solids and refrain from drinking with meals as this is believed to prolong satiety. The role of food consistency and satiety following LAGB is largely uninvestigated. The purpose of the study was to: (1) determine if food consistency impacts on post meal satiety in participants with well-adjusted LAGB and (2) compare the level of satiety achieved after consuming a solid versus a liquid meal between groups. METHODS: Twenty intervention (well-adjusted LAGB) and 20 control participants were recruited. All participants consumed three iso-caloric breakfasts that were randomised for nine mornings. Participants were asked to rate their satiety on visual analogue scales (VAS) at set times after the test meal. Areas under the curve (AUC) VAS scores were compared within and between groups. RESULTS: Solids (bars) with or without water provided greater satiety than the liquids (shakes) for both groups. Drinking water with the bar did influence satiety in the intervention group. For the intervention group (LAGB), AUC VAS values for the bar with water were 77.4 ± 11.2* and 72.4 ± 16.7* for the controls. CONCLUSION: Solid meals are more satisfying in both LAGB and non-LAGB individuals. However, a solid meal with accompanying water did not alter meal satiety.

Laparoscopic management of gastric band erosions: a 10-year series of 49 cases.

BACKGROUND: Intragastric erosion is a rare but major complication of laparoscopic adjustable gastric band (LAGB) surgery for morbid obesity. Many techniques to treat this problem have been described, with little supporting evidence. The authors review their experience with laparoscopic removal of eroded gastric bands. METHODS: The prospectively collected bariatric surgery database of the authors' practice was queried for the period January 2000 until February 2011, and the medical records for all patients with the diagnosis of band erosion were reviewed. Symptoms, time to erosion, interval between diagnosis and treatment, and complications of treatment were reviewed. All patients had undergone laparoscopy, cut-down onto the band, unclasping or division of the band near the buckle, removal of the band, and primary closure of the gastrotomy with omental patch reinforcement. RESULTS: During the study period, 2,097 LAGB operations were performed and 53 (2.53%) of these resulted in intragastric erosion. All the bands placed were LapBands (Allergan, Inc., Irvine, CA, USA). Erosions occurred with 14 of the 10-cm bands, 11 of the Vanguard bands, 14 of the AP Small bands, and 14 of the AP Large bands. Three patients elected to have their revisional surgery elsewhere and thus were lost to follow-up evaluation. One patient declined to have her band removed. The remaining 49 patients were included in the analysis. The mean time from band placement to the diagnosis of erosion was 31.5 months, and the mean time from diagnosis to band removal was 32 days. The mean hospital stay was 4 days. The complications included one postoperative leak, four superficial wound infections, and one pleural effusion. There were no deaths. CONCLUSIONS: This review demonstrates the safety of laparoscopic removal of eroded gastric bands with primary closure and omental patch repair. The time from diagnosis of erosion to treatment can be short, in contrast to endoscopic removal, in which the requirement for further erosion of the band to free the buckle often necessitates delayed treatment.

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy.

BACKGROUND: To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique. METHODS: We present a retrospective and prospective review of laparoscopic splenectomies over a 4-year period. Two chronological periods were studied, before and after the implementation of a standardized technique of a laparoscopic splenectomy involving: (i) hilar dissection with ultrasonic shears; (ii) two experienced laparoscopic surgeons; and (iii) trained dedicated equipment and staff using a checklist approach in the preparation and conduct of the operation. Two groups of patients were studied relating to the periods before and after the implementation of a standardized technique. Statistical methods used were the Wilcoxon's rank sum test and the two-sample test. RESULTS: Thirty-one laparoscopic splenectomies were attempted. The most common indication was for idiopathic thrombocytopenic purpura. When comparing the early phase (n = 15) with the standardized technique phase (n = 16), there was a significant reduction in conversion rates (40% vs 6%), operating times (218 min vs 171 min), complication rates (6 cases including 1 death vs none) and length of stay (11 days vs 4 days). The results were significant for reduction in hospital stay, conversion rates and complications rates. CONCLUSIONS: A reduction in conversion rates, operating time, morbidity and length of stay was realized during the learning curve of implementing laparoscopic splenectomy by adopting a standardized technique. This technique involved hilar dissection using the ultrasonic shears, two experienced laparoscopic surgeons performing the surgery, dedicated equipment and trained staff using the checklist approach. We recommend such a standardized technique in performing laparoscopic splenectomy.