Training model for laparoscopic Heller and Dor fundoplication: a tool for laparoscopic skills training and assessment-construct validity using the GOALS score.

BACKGROUND: Laparoscopic training demands practice. The transfer of laparoscopic skills from training models to real surgical procedures has been proven. The global operative assessment of laparoscopic skills (GOALS) score is a 5-item global rating scale developed to evaluate laparoscopic skills by direct observation. This scale has been used to demonstrate construct validity of several laparoscopic training models. Here, we present a low-cost model of laparoscopic Heller-Dor for advanced laparoscopic training. The aim of this study was to determine the capability of a training model for laparoscopic Heller-Dor to discriminate between different levels of laparoscopic expertise. METHODS: The performance of two groups with different levels of expertise, novices (<30 laparoscopic procedures PGY1-2) and experts (>300 laparoscopic procedures PGY4-5) was assessed. All participants were instructed to perform two tasks (esophageal myotomy and fundoplication). All the performances were recorded in a digital format. A laparoscopic expert who was blinded to subject's identity evaluated the recordings using the GOALS score. Autonomy, one of the five items of GOALS, was removed since the evaluator and the trainee did not have interaction. The time required to finish each task was also recorded. Performance was compared using the Mann-Whitney U test (p < 0.05 was significant). RESULTS: Twenty subjects were evaluated: ten in each group, using the GOALS score. The mean total GOALS score for novices was 7.5 points (SD: 1.64) and 13.9 points (SD: 1.66) for experts (p < 0.05).The expert group was superior in each domain of the GOALS score compared to novices: depth perception (mean: 3.3 vs 2 p < 0.05), bimanual dexterity (mean 3.4 vs 2.1 p < 0.05), efficiency (mean 3.4 vs 1.7 p < 0.05) and tissue handling (mean 3.6 vs 1.7 p < 0.05). With regard to time, experts were superior in task 1 (mean 9.7 vs 14.9 min p < 0.05) and task 2 (mean 24 vs 47.1 min p < 0.05) compared to novices. CONCLUSIONS: The laparoscopic Heller-Dor training model has construct validity. The model may be used as a tool for training of the surgical resident.

Gastrojejunal Anastomosis Perforation after Gastric Bypass on a Patient with Underlying Pancreatic Cancer: A Case Report and Review of the Literature.

Introduction. We describe a case of gastrojejunal anastomosis perforation after gastric bypass on a patient with underlying pancreatic cancer. Case Description. A 54-year-old female with past surgical history of gastric bypass for morbid obesity and recent diagnosis of unresectable pancreatic cancer presents with abdominal pain, peritonitis, and sepsis. Computerized axial tomography scan shows large amount of intraperitoneal free air. The gastric remnant is markedly distended and a large pancreatic head mass is seen. Intraoperative findings were consistent with a perforated ulcer located at the gastrojejunal anastomosis and a distended gastric remnant caused by a pancreatic mass invading and obstructing the second portion of the duodenum. The gastrojejunal perforation was repaired using an omental patch. A gastrostomy for decompression of the remnant was also performed. The patient had a satisfactory postoperative period and was discharged on day 7. Discussion. Perforation of the gastrojejunal anastomosis after Roux-en-Y gastric bypass is an unusual complication. There is no correlation between the perforation and the presence of pancreatic cancer. They represent two different conditions that coexisted. The presence of a gastrojejunal perforation made the surgeon aware of the advanced stage of the pancreatic cancer.

Femoral hernia sac laparoscopy: a case report.

We present the case of a 64-year-old female with an incarcerated right femoral hernia, associated with a small bowel obstruction that was successfully treated with an open femoral hernia repair with plug. At the same time we performed a hernia sac laparoscopy to evaluate the viability of the previously reduced small bowel. The hernioscopy was performed with a 0° 5 mm scope with reliable evaluation of the peritoneal cavity. We confirm that hernioscopy is a safe and feasible procedure and provides useful information for the appropriate management of acute incarcerated femoral/inguinal hernias.

Antibióticos profilácticos en apendicitis aguda: evaluación de un protocolo / Prophylactic antibiotics in acute appendicitis: evaluation of a protocol

Entre el 1º de abril de 1999 y el 31 de marzo del 2001 se realizaron en el Hospital Universitario Clínica San Rafael (HUCSR) de Bogotá, 732 apendicetomías por el diagnóstico de apendicitis aguda en pacientes mayores de 15 años. Hemos realizado un estudio retrospectivo de 100 de estos casos antes de la introducción de un protocolo de sulbactam/ampicilina y 100 casos después del protocolo en busca de los resultados del tratamiento con antibióticos profiláctico, comparando ambos grupos, buscando la incidencia de infección del sitio operatorio (ISO), estancia, antibióticos utilizados, dosis, combinaciones y costos de los mismos. Los resultados muestran que el comportamiento en ambos es similar en estancia (1.58 vs. 1.72 días) y aparición de ISO (3 por ciento vs. 4p por ciento), en el grupo con protocolo y sin protocolo respectivamente, y que el uso de antibióticos profilácticos con protocolo presenta una disminución en costos ($45.000 vs. $82.587), dosis (1 vs. 2.95), combinaciones y número de antibióticos utilizados (1 vs. 1.19).Lo anterior nos muestra que una utilización racional y adecuada de la profilaxis antibiótica redunda en beneficios para el paciente y la institución...

Linfangioma esplenico / Splenic lymphagioma

El linfangioma esplénico es una rara neoplasia benigna caracterizada por dilataciones quisticas de vasos linfáticos en el parenquima del bazo. El linfangioma puede comprometer el bazo solamente, o múltiples organos. Describe el caso de una mujer de 49 años de edad con diagnóstico de linfangioma esplénico, quien presentó un cuadro de trombocitopenia de tres años de evolución; se realizó tratamiento médico con interferón durante seis meses sin mejoría y esplenectomía, con hallazgos macroscópicos de patología compatibles con linfangioma esplénico. Además, se realizó una evisión actualizada de la literatura, discutiendo su diagnóstico diferencial, pronóstico y opciones de tratamiento.