Immediate versus delayed removal of urinary catheter after laparoscopic hysterectomy: a randomised controlled trial.

OBJECTIVE: To evaluate if immediate catheter removal (ICR) after laparoscopic hysterectomy is associated with similar retention outcomes compared with delayed removal (DCR). STUDY DESIGN: Non-inferiority randomised controlled trial. POPULATION: Women undergoing laparoscopic hysterectomy in six hospitals in the Netherlands. METHODS: Women were randomised to ICR or DCR (between 18 and 24 hours after surgery). PRIMARY OUTCOME: The inability to void within 6 hours after catheter removal. RESULTS: One hundred and fifty-five women were randomised to ICR (n = 74) and DCR (n = 81). The intention-to-treat and per-protocol analysis could not demonstrate the non-inferiority of ICR: ten women with ICR could not urinate spontaneously within 6 hours compared with none in the delayed group (risk difference 13.5%, 5.6-24.8, P = 0.88). However, seven of these women could void spontaneously within 9 hours without additional intervention. Regarding the secondary outcomes, eight women from the delayed group requested earlier catheter removal because of complaints (9.9%). Three women with ICR (4.1%) had a urinary tract infection postoperatively versus eight with DCR (9.9%, risk difference -5.8%, -15.1 to 3.5, P = 0.215). Women with ICR mobilised significantly earlier (5.7 hours, 0.8-23.3 versus 21.0 hours, 1.4-29.9; P ≤ 0.001). CONCLUSION: The non-inferiority of ICR could not be demonstrated in terms of urinary retention 6 hours after procedure. However, 70% of the women with voiding difficulties could void spontaneously within 9 hours after laparoscopic hysterectomy. It is therefore questionable if all observed urinary retention cases were clinically relevant. As a result, the clinical advantages of ICR may still outweigh the risk of bladder retention and it should therefore be considered after uncomplicated laparoscopic hysterectomy. TWEETABLE ABSTRACT: The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.

Implementation of laparoscopic hysterectomy: maintenance of skills after a mentorship program.

BACKGROUND: To evaluate the implementation and maintenance of advanced laparoscopic skills after a structured mentorship program in laparoscopic hysterectomy (LH). METHODS: Cohort retrospective analysis of 104 successive LHs performed by two gynecologists during and after a mentorship program. LHs were compared for indication, patient characteristics and intraoperative characteristics. As a frame of reference, 94 LHs performed by the mentor were analyzed. RESULTS: With regard to indication, blood loss and adverse outcomes, both trainees performed LHs during their mentorship program comparable with the LHs performed by the mentor. The difference in mean operating time between trainees and mentor was not clinically significant. Both trainees progressed along a learning curve, while operating time remained statistically constant and comparable to that of the mentor. After completing the mentorship program, both gynecologists maintained their acquired skills as blood loss, adverse outcome rates and operating time were comparable with the results during their traineeship. CONCLUSION: A mentorship program is an effective and durable tool for implementing a new surgical procedure in a teaching hospital with respect to patient safety aspects, as indications, operating time and adverse outcome rates are comparable to those of the mentor in his own hospital during and after completing the mentorship program.

Implementation of advanced laparoscopic surgery in gynecology: national overview of trends.

STUDY OBJECTIVE: To estimate the implementation of laparoscopic surgery in operative gynecology. DESIGN: Observational multicenter study (Canadian Task Force classification II-2). SETTING: All hospitals in the Netherlands. SAMPLE: Nationwide annual statistics for 2002 and 2007. INTERVENTIONS: A national survey of the number of performed laparoscopic and conventional procedures was performed. Laparoscopy was categorized for complexity in level 1, 2, and 3 procedures. Outcomes were compared with results from 2002 to evaluate trends. MEASUREMENTS AND MAIN RESULTS: In 2002, 21 414 laparoscopic and 9325 conventional procedures were performed in 74 hospitals (response rate, 74%), and in 2007, 16 863 laparoscopic and 10 973 conventional procedures were performed in 80 hospitals (response rate, 80%). Compared with 2002, in 2007, level 1 procedures were performed significantly less often and level 2 and level 3 procedures were performed significantly more often. The mean number of performed laparoscopic procedures per hospital decreased from 289 to 211 procedures. Teaching hospitals performed more than twice as many therapeutic laparoscopic procedures as nonteaching hospitals do. Cystectomy, oophorectomy, and ectopic pregnancy surgery were preferably performed using the laparoscopic approach. Laparoscopic hysterectomy was performed significantly more often, accounting for 10% of all hysterectomies. Annually, 20% of hospitals in which laparoscopic hysterectomy was implemented performed 50% of all laparoscopic hysterectomies, and 50% of the hospitals performed 20% of laparoscopic hysterectomies. CONCLUSION: This study describes increasing implementation of therapeutic laparoscopic gynecologic surgery. Clinics increasingly opt to perform laparoscopic surgery rather than conventional surgery. However, implementation of advanced procedures such as laparoscopic hysterectomy seems to be hampered.

Retention of basic laparoscopic skills after a structured training program.

The purpose of this study was to test the retention of basic laparoscopic skills on a box trainer 1 year after a short training program. For a prior study, eight medical students without prior experience (novices) underwent baseline testing, followed by five weekly training sessions and a final test. During each of seven sessions, they performed five tasks on an inanimate box trainer. Scores were calculated by adding up the time to completion of the task with penalty points, consequently rewarding speed and precision. The sum score was the sum of the five scores. One year later, seven of them underwent retention testing for the current study. The final test results were compared with retention test results as a measure of durability of acquired skills. Novices' scores did not worsen significantly for four out of five tasks (i.e., placing a pipe cleaner p = 0.46, placing beads p = 0.24, cutting a circle p = 0.31, and knot tying p = 0.13). However, deterioration was observed in the performance on stretching a rubber band (p < 0.05), as well as in the sum score (p < 0.05). Nevertheless, all retention scores remained better than the baseline results. In conclusion, basic laparoscopic skills acquired during a short training program merely sustain over time. However, ongoing practice is advisable, especially to preserve tissue-handling skills, since these may be the first to deteriorate.

The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system.

BACKGROUND: Eye-hand coordination problems occur during laparoscopy. This study aimed to investigate the difference in instrument movements between the surgeon him- or herself holding the camera and an assistant holding the camera during performance of a laparoscopic task and to check whether experience of the surgeon plays a role in this issue. METHODS: The participants were divided into three groups: experts, residents, and novices. Each participant performed positioning tasks using the right (R) and left (L) hands. During these tasks, the camera was manipulated either by the participant (C(self)) or by an assistant (C(assistant)). Movements of instruments were recorded with the authors' new TrEndo tracking system. The performance was analyzed using five kinematic parameters: time, path length, three-dimensional (3D) motion smoothness, 1D motion smoothness (along the axis), and depth perception. RESULTS: A total of 46 participants contributed. Three tests were performed: test 1-LC(self), test 2-LC(assistant), and test 3-RC(assistant). In all the tests, the experts performed better than the residents and novices in terms of time, path length, and depth perception. The novices performed better in tests 1-LC(self) and 2-LC(assistant) than in test 3-RC(assistant) in terms of path length, 3D motion smoothness, and depth perception. CONCLUSIONS: Laparoscopic experience and the camera-holding factor influenced the performance of laparoscopic tasks on the simulator. Time, path length, and depth perception clearly discriminate between different levels of experience in laparoscopy, whereas 3D and 1D motion smoothness play a limited role. Novices experienced more difficulties when an assistant held the camera. Therefore, self-manipulation of the camera seems to improve novices' eye-hand coordination.

Implementation of the laparoscopic simulator in a gynecological residency curriculum.

BACKGROUND: In view of the current emphasis on increasing patient safety and quality control in laparoscopic surgery, there is a growing need to improve laparoscopic training. This study was conducted to investigate if and when residents reached performance standards for basic laparoscopic skills on a boxtrainer and to analyze the current state of implementation of laparoscopic simulators in a gynecological residency curriculum. METHODS: Residents across all 6 years of residency (postgraduate year [PGY] 1-6) were tested once on our boxtrainer by performing five inanimate tasks (pipe cleaner, rubber band, beads, cutting circle, intracorporeal knot tying). A sumscore for the five tasks was calculated for each participant (sum of all scores). Scores were calculated by adding completion time and penalty points, thus rewarding both speed and precision. These data were compared with scores of laparoscopic experts, which were set as performance standards. RESULTS: Of the participants, 111 were residents (7 PGY1, 27 PGY2, 29 PGY3, 28 PGY4, 14 PGY5, 6 PGY6) and 8 were experts. At the end of residency, PGY6 residents reached the performance standard for all tasks except intracorporeal knot tying. It was not until PGY5 that residents reached the performance standard for the pipe cleaner task; PGY1, for rubber band; PGY5, for beads; PGY4, for circle cutting; and PGY6, for sumscore. Throughout residency PGY6 had a mean total of only 3.6 h of simulator training experience. No correlation was found between this previous voluntary simulator training experience and performance on our boxtrainer during this study (sumscore), and between previous voluntary simulator training and total laparoscopic procedures performed. In a combined multivariate analysis, sumscore performance remained significantly associated with the number of laparoscopic procedures performed by residents when they were working as as a primary surgeon (p = 0.002), and not with the cumulative hours of simulator training during residency prior to participating in this study (p = 0.15). CONCLUSIONS: In a current Dutch gynecological residency curriculum, residents do not reach all performance standards for basic laparoscopic skills on the boxtrainer. We conclude that the voluntary simulator training program has a substantial risk to fail and that the implementation of the laparoscopic skills simulator in the current residency curriculum is in its infancy.

Implementation of advanced laparoscopy into daily gynecologic practice: difficulties and solutions.

BACKGROUND: The implementation of laparoscopy into Dutch gynecologic practice is slow. This study was conducted to assess the current state of laparoscopy, to identify factors influencing the implementation and to find solutions toward a better implementation. METHODS: In 2003 a questionnaire was sent to all 151 gynecologists who finished residency within the previous 5 years. The questionnaire addressed practice demographics, performance of laparoscopy, factors influencing use of laparoscopy in practice and means of obtaining laparoscopic skills after residency. RESULTS: Of 151 gynecologists, 124 (82%) responded, 46 (37%) male and 78 (63%) female. Mean age was 39 years (range 32-47 years). Respondents (73%) believed they were adequately trained during residency for basic laparoscopic procedures, but not for the more advanced procedures (82%). Lack of caseload, lack of being a primary surgeon, and lack of simulator training caused the deficiency of laparoscopic skills at the end of the residency. Causes of the slow implementation were long operating time, lack of attention for laparoscopy during residency, and budgetary problems, but not the financial compensation for gynecologists. In current practice, only 9% believed they reached their preferred level of competence. Hiring an advanced laparoscopic gynecologist was believed to be the best opportunity to reach the preferred level of competence. A minority of respondents supported a referral system or fellowship program. CONCLUSIONS: Basic laparoscopy is sufficiently mastered during residency training; however, advanced laparoscopy is not. More emphasis should be placed on laparoscopic training of advanced procedures during residency and for gynecologists in practice. Hiring a gynecologist with advanced laparoscopic skills is expected to be the solution for this problem. However, a referral system or fellowship program is not.

Gynecological laparoscopy in residency training program: Dutch perspectives.

BACKGROUND: Implementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation. METHODS: In 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency. RESULTS: Of the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents' laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills. CONCLUSIONS: Incorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.

[Ototoxicity induced by clarithromycin]. / Door claritromycine geïnduceerde ototoxiciteit.

A 76-year-old man developed a progressive bilateral hearing loss 4 days after starting a high dose of clarithromycin for atypical pulmonary tuberculosis. When the clarithromycin was discontinued the hearing improved subjectively but it worsened again upon reexposure. Halving the dose resulted in both an objective and subjective improvement in hearing, yet the original level of hearing was only obtained once clarithromycin had been permanently withdrawn. It would seem that this adverse effect is dose dependent. This seems to be the first published case study that demonstrates ototoxicity as a result of clarithromycin use.

Adventitial stripping does not strip the adventitia.

This study investigates the process of stripping the adventitia off a blood vessel, which is a normal procedure prior to performing a microvascular anastomosis. In five rats, the common carotid and the superficial femoral arteries of one side were stripped sharply, whereas the arteries of the other side were left unstripped to serve as controls. In a further set of five rats, the arteries were stripped bluntly. Immediately following stripping, experimental and control arterial segments were removed. Histology of cross sections of the segments was studied. In no case was there complete removal of the adventitia. When stripped and control arterial sections were compared, no significant difference between cross-sectional adventitial areas could be demonstrated. Morphologic study revealed that stripping mainly removes large collagen fibers from the adventitia. The small collagen fibrils that are still in place fan out in such a way that although considerable tissue is removed, the volume that the adventitia occupies remains the same. Stripping the adventitia does not cause complete removal of the adventitia, and in this study no significant reduction in the adventitial volume could be found. Stripping does, however, allow a better view of the cut edge of the vessel wall under an operating microscope. Since blunt stripping could cause damage to other vessel wall layers, sharp stripping is to be preferred.

Changes in the carpal tunnel due to action of the flexor tendons: visualization with magnetic resonance imaging.

Successive cross-sectional areas (CSA) of the carpal tunnel were measured with the fingers in both extension and full flexion in 12 healthy volunteers using magnetic resonance imaging. During flexion, lumbrical muscles could be observed to move into the carpal tunnel up to different levels in all volunteers. For each of the volunteers, the level of the hook of hamate was used as the reference level. The mean CSA measured at this level was considerably larger in flexion than in extension: 191 mm2 (SD, +/- 26) and 169 mm2 (SD, +/- 15), respectively (p = .004). In three volunteers, no difference in CSA between extension and flexion was measured at the hamate level, despite the presence of lumbrical muscles, whereas in these same volunteers at levels more distal, the CSA clearly increased during flexion. The mean CSA for extension and flexion distal and just proximal to the smallest level differed significantly, but the absence of expansion was noticed only at the smallest level. Other changes that were frequently observed during flexion were fat compression, flattening and displacement of the median nerve, and pressure on the superficial and deep flexor tendons.