The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club

Minimally invasive video-assisted total thyroidectomy: an easy to learn technique for skillful surgeons

BACKGROUND

Minimally invasive video-assisted total thyroidectomy (MIVATT) is a treating option for small thyroids that demands skills required for both traditional thyroidectomy and endoscopic surgery. This prospective study aims to define the learning curve for MIVATT for residents, with experience in traditional thyroid and laparoscopic surgery.

METHODS

In all, 36 MIVATTs for benign disease were evenly divided among 4 residents. We recorded and analyzed: age, sex, pathology, thyroid weight, duration of the operation, ΔCa (postoperative minus preoperative calcemia), ΔWBC (postoperative minus preoperative white blood cell count), vocal motility, operative difficulty, postoperative vocal alteration, postoperative pain, complications, gram of gland excised per minute of the operation, conversion, and hospitalization.

RESULTS

Statistically significant differences were observed in the different learning points, between duration of surgery (p < .001), operative difficulty (p = .022), grams of gland excised per minute of operation (p < .001), and WBC (p = .011).

CONCLUSIONS

Surgeons that are experience in both thyroid and endoscopic surgery are subjects to a short learning curve concerning MIVATT.

Bile duct injury and use of cholangiography during laparoscopic cholecystectomy

BACKGROUND

Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC).

METHODS

Data for patients from 114 Swiss institutions who underwent LC for acute or chronic cholecystitis between 1995 and 2005 were used in univariable and logistic regression analyses.

RESULTS

In total 31 838 patients, mean(s.d.) age 54·4(15·9) years, were analysed. The incidence of BDI was 0·3 per cent (101 patients), which did not change over time (P = 0·560). Univariable analysis revealed that male patients had a higher risk of BDI (0·5 per cent versus 0·2 per cent in female patients; P = 0·001), as did patients whose operation lasted at least 150 min (1·1 per cent versus 0·1 per cent for operating time of less than 150 min; P < 0·001). Logistic regression confirmed male sex (odds ratio (OR) 1·89, 95 per cent confidence interval 1·27 to 2·81) and prolonged surgery (OR 12·60, 10·87 to 23·81) as independent risk factors. Comparison of groups with and without intraoperative cholangiography showed no difference in the incidence of BDI (both 0·3 per cent; P = 0·755) and BDIs missed during surgery (10 versus 8 per cent; P = 0·737).

CONCLUSION

Male sex and prolonged laparoscopic surgery are independent risk factors for BDI during LC. Frequent use of IOC does not seem to reduce BDI or the number of injuries missed during surgery.

Laparoscopic cholecystectomy conversion rates two decades later

BACKGROUND AND OBJECTIVES

Now nearly 2 decades into the laparoscopic era, nationwide laparoscopic cholecystectomy conversion rates remain around 5% to 10%. We analyzed patient- and surgeon-specific factors that may impact the decision to convert to open.

METHODS

We retrospectively analyzed 2205 LCs performed at a large tertiary community hospital over a 52 month period (May 2004 through October 2008).

RESULTS

The overall conversion rate was 4.9%. The most common reason for conversion was adhesions, and the majority of these patients had prior abdominal surgery. Males and patients >50 years old had a significantly higher likelihood of open conversion. The conversion rate of high-volume surgeons (≥100 total cases) in comparison to low-volume surgeons (40 to 99 total cases) was significantly lower. Conversion rates were lower among surgeons with fellowship training and those who completed residency training after 1990. Interestingly, the percentage of conversions due to technical difficulty was lower among those with fellowship training but higher among those who completed training after 1990.

CONCLUSION

Conversion occurred in ∼5% of all laparoscopic cholecystectomies. Males, patients >50 years old, and cases performed by low-volume surgeons had a higher likelihood of conversion. Other surgeon-specific factors did not have a significant impact on conversion rate.

Management of patients who return to the hospital with a bile leak after laparoscopic cholecystectomy

INTRODUCTION

Bile leaks after laparoscopic cholecystectomy (LC) can be difficult to diagnose early. The aim of this study was to investigate the clinical features of minor bile leaks and to discuss how to manage patients who revisit the hospital with minor bile leaks after LC.

PATIENTS AND METHODS

From January 2001 to September 2007, 2219 LCs were performed at the Ajou University Medical Center. Twenty-four patients (1.0%) who presented with a bile leak or bile duct injury after a cholecystectomy were identified. The patients with minor bile duct injury were divided into two groups, depending on whether they revisited the hospital (group 2) or not (group 1) after LC.

RESULTS

Seventeen of 24 patients had minor bile leaks. The characteristics of patients in group 2 were long hospital stay, short operation time, and low frequency of indwelling surgical drains. Ten of 17 patients (58.8%) revisited the hospital at a mean of 7.0 +/- 2.7 days after the LC. However, 3 of 10 patients (30%) were discharged from the ER with atypical abdominal pain and returned to the hospital again within 5 days due to recurrent abdominal pain. There was a significant correlation between hospital stay and time to endoscopic retrograde cholangiopancreatography (ERCP) (P = 0.008) and between hospital stay and PCD (P = 0.028).

CONCLUSIONS

Most minor bile leaks were managed by ERCP and/or percutaneous drainage. However, early diagnosis was difficult when patients revisited the hospital within 7 days after the LC. Therefore, early ERCP should be considered in these patients to diagnose the bile leak early and limit needed hospital stay.

The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe

BACKGROUND

The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety.

STUDY DESIGN

We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications.

RESULTS

One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts.

CONCLUSIONS

For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients

OBJECTIVE

To analyze patient outcome in the first 14 months of the German natural orifice translumenal endoscopic surgery (NOTES) registry (GNR).

SUMMARY BACKGROUND DATA

NOTES is a new surgical concept, which permits scarless intra-abdominal operations through natural orifices, such as the mouth, vagina, rectum, or urethra. The GNR was established as a nationwide outcome database to allow the monitoring and safe introduction of this technique in Germany.

METHODS

The GNR was designed as a voluntary database with online access. All surgeons in Germany who performed NOTES procedures were requested to participate in the registry. The GNR recorded demographical and therapy data as well as data on the postoperative course.

RESULTS

A total of 572 target organs were operated in 551 patients. Cholecystectomies accounted for 85.3% of all NOTES procedures. All procedures were performed in female patients using transvaginal hybrid technique. Complications occurred in 3.1% of all patients, conversions to laparoscopy or open surgery in 4.9%. In cholecystectomies, institutional case volume, obesity, and age had substantial effect on conversion rate, operation length, and length of hospital stay, but no effect on complications.

CONCLUSIONS

Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application. Transvaginal hybrid NOTES cholecystectomy is a practicable and safe alternative to laparoscopic resection even in obese or older patients.

Single-incision laparoscopic surgery (SILS™) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator

BACKGROUND

Single-incision laparoscopic surgery (SILS™) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS™ may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS™ technique.

METHODS

Medical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILS™-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILS™, the subjects used an FLS box-trainer modified to accept a SILS Port™ with two working ports for instruments and one port for a 30° 5-mm laparoscope. SILS™ tasks were performed with instruments capable of unilateral articulation. SILS™ suturing was performed both with and without an articulating EndoStitch™ device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILS™ FLS score (SS), were calculated using standard time and accuracy metrics.

RESULTS

There were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILS™ suturing using the articulating suturing device was superior to the use of a modified needle driver technique.

CONCLUSIONS

SILS™ is more technically challenging than standard laparoscopic surgery. Using currently available SILS™ platforms and instruments, even surgeons with SILS™ experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILS™.

Missing Productivity Gains in the Medicare Physician Fee Schedule: Where Are They?

The Medicare Fee Schedule with payments for thousands of visits and procedures is updated periodically for the work component of changes in physician relative work. Three 5-year reviews of physician work by Medicare have been biased against finding productivity gains and reductions in physician work relative values. The authors present four studies showing shorter physician times with patients in their offices and in the operating room, increases in surgeons’ self-reported total work in spite of declining operating room times, and growing numbers of costly handoffs to nonsurgeons, while surgeons receive full payment for postoperative follow-up with patients. Substantial savings exist in the fee schedule if productivity gains from greater delegation to ancillary staff and specialists, reengineering of services, and rapid learning by experience with new technologies were integrated into the periodic reviews.

Review of available methods of simulation training to facilitate surgical education

The old paradigm of "see one, do one, teach one" has now changed to "see several, learn the skills and simulation, do one, teach one." Modern medicine over the past 30 years has undergone significant revolutions from earlier models made possible by significant technological advances. Scientific and technological progress has made these advances possible not only by increasing the complexity of procedures, but also by increasing the ability to have complex methods of training to perform these sophisticated procedures. Simulators in training labs have been much more embraced outside the operating room, with advanced cardiac life support using hands-on models (CPR "dummy") as well as a fusion with computer-based testing for examinations ranging from the United States medical licensure exam to the examinations administered by the American Board of Surgery and the American Board of Colon and Rectal Surgery. Thus, the development of training methods that test both technical skills and clinical acumen may be essential to help achieve both safety and financial goals.

Predictors of major complications after laparoscopic cholecystectomy: surgeon, hospital, or patient?

BACKGROUND

Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists about whether more common procedures should be performed at high-volume centers. Using mortality alone to assess routine operations is hampered by relatively low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications after laparoscopic cholecystectomy (LC).

STUDY DESIGN

Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed. Univariate and multivariable analyses were performed and independent risk factors of complications were identified.

RESULTS

A total of 1,102,071 weighted patient discharges were identified, with a complication rate of 6.8%. Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates (p < 0.0001). Higher surgeon volume (>or=36/year versus <12/year) and higher hospital volume (>or=225/year versus <or=120/year) were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively; p < 0.0001). Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years; adjusted odds ratio [AOR] = 2.16; 95% CI, 2.01-2.32), male gender (AOR = 1.14; 95% CI, 1.10-1.19), and comorbidities (Charlson Comorbidity Score 2 versus 0; AOR = 2.49; 95% CI, 2.34-2.65) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications.

CONCLUSIONS

Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.

A safe laparoscopic cholecystectomy depends upon the establishment of a critical view of safety

Bile duct injuries (BDI) during a laparoscopic cholecystectomy (LC) occur more frequently than during an open cholecystectomy. Many expert surgeons learn to perform procedures safely based on their experience. Above all, the critical view of safety (CVS) introduced by Strasberg in 1995 is the standard practice to prevent BDI during an LC. The CVS is achieved by clearing all fat and fibrous tissue in Calot's triangle, after which the cystic structures can be clearly identified, occluded, and divided. Failure to successfully create this view may be an indication for conversion to an open cholecystectomy. The Japan Society for Endoscopic Surgery (JSES) introduced an accreditation examination in 2004. The critical view is an important factor used to judge a safe dissection. The annual ratios of successful applicants were 63% in 2004, 45% in 2005, 36% in 2006, 39% in 2007, and 44% in 2008. Biennial questionnaire surveys by JSES show that the laparoscopic BDI rates were 0.66% in 1990-2001, 0.79% in 2002, 0.77% in 2003, 0.66% in 2004, 0.77% in 2005, 0.65% in 2006, and 0.58% in 2007. Therefore, 2007 was the first year in which the rate was below 0.6%. A decreasing BDI rate is therefore expected because successful candidates will introduce technical improvements to colleagues in their hospitals and local regions.

Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool

Background

Awareness of the relative high rate of adverse events in laparoscopic surgery created a need to safeguard quality and safety of performance better. Technological innovations, such as integrated operating room (OR) systems and checklists, have the potential to improve patient safety, OR efficiency, and surgical outcomes. This study was designed to investigate the influence of the integrated OR system and Pro/cheQ, a digital checklist tool, on the number and type of equipment- and instrument-related risk-sensitive events (RSE) during laparoscopic cholecystectomies.

Methods

Forty-five laparoscopic cholecystectomies were analyzed on the number and type of RSE; 15 procedures were observed in the cart-based OR setting, 15 in an integrated OR setting, and 15 in the integrated OR setting while using Pro/cheQ.

Results

In the cart-based OR setting and the integrated OR setting, at least one event occurred in 87% of the procedures, which was reduced to 47% in the integrated OR setting when using Pro/cheQ. During 45 procedures a total of 57 RSE was observed—most were caused by equipment that was not switched on or with the wrong settings. In the integrated OR while using Pro/cheQ the number of RSE was reduced by 65%.

Conclusions

Using both an integrated OR and Pro/cheQ has a stronger reducing effect on the number of RSE than using an integrated OR alone. The Pro/cheQ tool supported the optimal workflow in a natural way and raised the general safety awareness amongst all members of the surgical team. For tools such as integrated OR systems and checklists to succeed it is pivotal not to underestimate the value of the implementation process. To further improve safety and quality of surgery, a multifaceted approach should be followed, focusing on the performance and competence of the surgical team as a whole.

Nintendo Wii video-gaming ability predicts laparoscopic skill

BACKGROUND

Studies using conventional consoles have suggested a possible link between video-gaming and laparoscopic skill. The authors hypothesized that the Nintendo Wii, with its motion-sensing interface, would provide a better model for laparoscopic tasks. This study investigated the relationship between Nintendo Wii skill, prior gaming experience, and laparoscopic skill.

METHODS

In this study, 20 participants who had minimal experience with either laparoscopic surgery or Nintendo Wii performed three tasks on a Webcam-based laparoscopic simulator and were assessed on three games on the Wii. The participants completed a questionnaire assessing prior gaming experience.

RESULTS

The score for each of the three Wii games correlated positively with the laparoscopic score (r = 0.78, 0.63, 0.77; P < 0.001), as did the combined Wii score (r = 0.82; P < 0.001). The participants in the top tertile of Wii performance scored 60.3% higher on the laparoscopic tasks than those in the bottom tertile (P < 0.01). Partial correlation analysis with control for the effect of prior gaming experience showed a significant positive correlation between the Wii score and the laparoscopic score (r = 0.713; P < 0.001). Prior gaming experience also correlated positively with the laparoscopic score (r = 0.578; P < 0.01), but no significant difference in the laparoscopic score was observed when the participants in the top tertile of experience were compared with those in the bottom tertile (P = 0.26).

CONCLUSIONS

The study findings suggest a skill overlap between the Nintendo Wii and basic laparoscopic tasks. Surgical candidates with advanced Nintendo Wii ability may possess higher baseline laparoscopic ability.

Current status of surgical management of acute cholecystitis in the United States

BACKGROUND

We attempted to determine population-based outcomes of laparoscopic (LC) and open cholecystectomy (OC) for acute cholecystitis (AC).

METHODS

We used the National Hospital Discharge Surveys from 2000 through 2005. Annual medical and demographic data from a national sample of discharge records from nonfederal, short-stay hospitals were queried. We identified all patients who underwent LC or OC for AC. The main outcome measures were the rate of LC or OC and in-hospital morbidity and mortality. One million patients underwent cholecystectomy (859,747 LCs; 152,202 OCs) for AC during 2000-2005.

RESULTS

Of the cases started laparoscopically, 9.5% were converted to OC. Compared to OC, patients who underwent LC were more likely to be discharged home (91% vs. 70%), carry private insurance (47% vs. 30%), suffer less morbidity (16% vs. 36%), and have a lower unadjusted mortality (0.4% vs. 3.0%). OC was associated with a 1.3-fold increase (95% confidence interval 1.1-1.4) in perioperative morbidity compared to LC after adjusting for patient and hospital factors.

CONCLUSIONS

Most patients in the 21st century with AC undergo LC with a low conversion rate and low morbidity. In the general population with acute cholecystitis, LC results in lower morbidity and mortality rates than OC even in the setting of open conversion.

Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload

BACKGROUND

Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room.

METHODS

Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastro-gastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da Vinci) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects' self-reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered significant.

RESULTS

Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595 +/- 22 s versus 459 +/- 137 s, respectively; p < 0.001), achieve higher overall scores (0 +/- 1 versus 95 +/- 128, respectively; p < 0.001), and commit fewer errors per knot (1.15 +/- 1.35 versus 0.05 +/- 0.26, respectively; p < 0.001). Subjects' overall score did not improve between the first and third attempt for laparoscopic suturing (0 +/- 0 versus 0 +/- 0; p = NS) but improved significantly for robotic suturing (49 +/- 100 versus 141 +/- 152; p < 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99 +/- 15 versus 57 +/- 23; p < 0.001).

CONCLUSIONS

Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed.

Retention of arthroscopic shoulder skills learned with use of a simulator. Demonstration of a learning curve and loss of performance level after a time delay

BACKGROUND

In orthopaedic surgery, arthroscopy is an irreplaceable diagnostic and interventional tool, and its breadth of use is increasing. The aim of this study was to investigate the surgeon's capacity for retention of an unfamiliar arthroscopic skill.

METHODS

Six fellowship-trained lower-limb surgeons were given standardized instruction regarding the performance of an arthroscopic Bankart suture on a laboratory-based simulator. They performed three single Bankart sutures on each of four occasions, one to two weeks apart. Six months later, the same surgeons repeated the study. They received no further instruction or guidance. Their performance was objectively assessed with use of validated motion-analysis equipment to record the total path length of the surgeon's hands, number of hand movements, and time taken to perform the sutures.

RESULTS

A learning curve showing significant and objective improvement in performance was demonstrated for all outcome parameters in both experiments (p < 0.005). The learning curve at six months was a repeated learning curve showing no significant difference from the initial learning curve.

CONCLUSIONS

This study objectively demonstrated a loss of all of the initial improvement in the performance of an arthroscopic Bankart suture following a six-month interval in which the surgeons did not do the procedure.

Validation of data and indicators in the Danish Cholecystectomy Database

OBJECTIVE

In The Danish Cholecystectomy Database (DCD), quality indicators are derived from clinical data in combination with administrative data from the National Patient Registry. The indicators 'Length of postoperative stay < or =1 day and no readmission', 'Length of stay (LOS) >3 days and/or readmission', 'Additional procedures within 30 days', 'Reconstructive bile duct surgery', 'Other surgery of the bile duct' and 'Death within 30 days' are all derived from administrative data. This study investigates the validity of the administrative data and evaluates the association between these indicators and postoperative complications.

RESEARCH DESIGN AND SUBJECTS

Data from 1360 medical records of patients undergoing cholecystectomy were compared with the relevant administrative data from the National Patient Registry. The medical records served as the 'gold standard'. The association between the individual indicators and the occurrence of a postoperative complication was assessed.

MEASURES

Validation of administrative data against the gold standard was done by the calculation of per cent agreement (including kappa-values) sensitivity/specificity and predictive values. The association between indicators and complications was analysed with crude event rates and odds ratios.

RESULTS

The validity of the administrative data was excellent (97.1-100% agreement, kappa = 0.73-1.00). All of the indicators except 'Other bile duct surgery' were significantly associated with postoperative complications. A subdivision of some indicators strengthened the associations.

CONCLUSIONS

The DCD is a valid method for monitoring the quality of cholecystectomy in Denmark.

Conversion after laparoscopic cholecystectomy in England

BACKGROUND

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors.

METHODS

Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year.

RESULTS

The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001).

CONCLUSIONS

Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has supplanted open cholecystectomy for most gallbladder pathology. Experience has allowed the development of now well-established technical nuances, and training has raised the level of performance so that safe LC is possible. If safe cholecystectomy cannot be performed because of acute inflammation, LC tube placement should occur. A systematic approach in every case to open a window beyond the triangle of Calot, well up onto the liver bed, is essential for the safe completion of the operation.

Patient safety, competency, and the future of surgical simulation

Despite its relatively short track record, simulation has been successfully introduced into the surgical arena in an effort to augment training. Initially a fringe endeavor at isolated centers, simulation has now become a mainstream component of surgical education. The surgical community is now aware that the old adage, "see one, do one, and teach one" is no longer acceptable from the ethical standpoint of practicing procedures on patients. Moreover, financial and time constraints have made teaching outside of the operating room an attractive proposition. Coupled with the growing body of validation, new procedures can now be practiced and proficiency can be acquired on a multitude of simulation platforms. Importantly, simulation standards are being established and there is an unprecedented national acceptance and endorsement of simulation as an invaluable educational tool; in fact, simulation is being mandated for surgical residency programs. Team training will likely expand the impact of surgical simulation considerably and help assure multidimensional competency verification. For both surgery residents and surgeons in practice, simulation holds great promise as a safe, effective, and efficient means of acquiring new skills.

Training on N.O.T.E.S.: from history we learn

Surgical errors occurring early in the learning curve of laparoscopic surgery providers delayed the uptake and progress of minimally invasive surgery (MIS) for years. This taught us a valuable lesson; innovations in surgical techniques should not be rapidly implemented until all aspects including applicability, feasibility and safety have been fully tested. In 2005, the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) published a white paper highlighting the barriers to NOTES development and identifying key elements for its progress. One of these elements is the training of future providers. Proficiency-based, virtual reality simulation will offer a feasible alternative to animal testing once the safety and efficacy parameters of NOTES are established. Recent advances in imaging including computed tomography (CT) scanning, magnetic resonance imaging (MRI) scanning, and ultrasound (US) scanning can offer improved image registration and real-time tracking. Combining these advanced imaging technologies with the newly designed virtual reality simulators will result in a fully comprehensive simulation curriculum which will offer a unique facility for future NOTES providers to train anytime, anywhere, and as much as they need to in order to achieve the pre-set proficiency levels for a variety of NOTES procedures. Furthermore they will incorporate patient-specific anatomical models obtained from patient imaging and uploaded onto the simulator to ensure face reliability and validity assurance. Training in a clean, safe environment with proximate feedback and performance analysis will help accelerate the learning curve and therefore improve patients' safety and outcomes in order to maximize the benefits of innovative access procedures such as NOTES.

Laparoscopic colonic resection in inflammatory bowel disease: minimal surgery, minimal access and minimal hospital stay

OBJECTIVE

Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding but can offer improved short-term outcomes. The introduction of minimally invasive surgery (MIS) as the default operative approach for IBD, however, may have inherent learning curve-associated disadvantages. We hypothesise that the establishment of MIS as the standard operative approach does not increase patient morbidity as assessed in the initial period of its introduction into a specialised unit, and that it confers earlier postoperative gastrointestinal recovery and reduced hospitalisation compared with conventional open resection.

METHOD

A case-control study was undertaken on laparoscopic resection (LR) vs open colon resection (OR) for IBD. The LR group was collated prospectively and compared with a pathologically matched historical control set. Outcomes measured included: postoperative length of stay, time to normal bowel function and postoperative morbidity. Statistical analysis was performed using spss.

RESULTS

Twenty-eight patients were investigated (14 LR, 14 OR). The two groups were matched for type of operation, type of disease and age. There were no conversions in the LR group. Morbidity and readmissions did not differ significantly between the groups. Those undergoing laparoscopic resection had a quicker return to diet (median 2 vs 4 days; P = 0.000002), time to first bowel motion (2 vs 4 days; P = 0.019) and shorter postoperative length of stay (5.5 vs 12.5; P = 0.0067).

CONCLUSION

These findings support the routine use of MIS for the elective surgical management of IBD in our department. Patients undergoing laparoscopic colectomies for IBD can expect faster return of gastrointestinal function and shorter hospitalisation.

Operative Strategy Can Reduce the Incidence of Major Bile Duct Injury in Laparoscopic Cholecystectomy

Major bile duct injury (BDI) rates remain in the range of 0.3 to 0.5 per cent for laparoscopic cholecystectomy (LC). The dominant surgical technique worldwide continues to be the “infundibular” technique of dissection that was popularized in the early 1990s. Proponents of the “critical view of safety” (CV) technique have suggested that most of these injuries are avoidable. The objective of our study was to determine whether routine use of the CV technique reduced the observed/expected single-institution rate of major BDI over a 5-year period in a teaching hospital. All patients (n = 3042) who underwent LC for any indication at one institution over a 60-month period were identified by database search. Major BDI was identified by Common Procedural Terminology codes indicating operative repair and confirmed by review of medical records. One patient sustained a transection–excision of the common duct requiring hepaticoduodenostomy. Based on published data, the observed BDI rate was one in nine to one in 15 of the expected rate. This represents an order-of-magnitude improvement in the safety of LC at a single institution where the majority of cases were performed by residents. We suggest that the “critical view” technique should be widely adopted.

[Virtual simulation of the human inguinal region]

At the present time the development of computers allows access to some three-dimensional models (3D) of physiological or pathological human situations obtained from patients with different medical or surgical problems. These models have a wide variety of applications: knowledge of the pathogenic mechanisms, help in diagnosis, planning of surgical strategies, training of surgical residents, teaching of medicine and surgery, design of devices and materials for use in medical and surgical practice or even distance interventions. Our objective is to design a 3D model of the inguinal region with the purpose of improving knowledge of the pathogenic mechanisms of inguinal hernia, the planning of surgical strategies and the teaching of the surgery of these hernias. They can also be used study the mechanical response of biomaterials into the abdominal wall.

Efficacy of sinonasal simulator in teaching endoscopic nasal skills

OBJECTIVES/HYPOTHESIS

To develop a nasal model (NM) which accurately simulates human texture and anatomy and to study the effect of training with NM on performance of video rigid nasal endoscopy and video flexible laryngoscopy. At the conclusion of this presentation, the participants should be able to demonstrate that training with nasal endoscopic simulation enhances efficiency and may improve comfort to the patient.

STUDY DESIGN

A randomized blinded control trial.

METHODS

Twenty medical students without prior endoscopic experience, stratified by prior video game experience, were randomized to training or no training on NM. All participants viewed a 15-minute video instruction on endoscopy. Students randomized to training then practiced on the NM for 15 minutes. All students were tested within 90 minutes of the initial instruction with a timed identification of structures on NM followed by a timed flexible laryngoscopy on a human volunteer who ranked comfort/discomfort on a visual analogue scale.

RESULTS

The students in the training group had a significantly shorter procedure time on NM using rigid nasal endoscopy compared with untrained students (61 seconds vs. 104 seconds, P = .025). The trained students showed a trend, which did not reach statistical significance, toward faster flexible laryngoscopy on the model (23 seconds vs. 32 seconds, P = .085). The trained students had average lower discomfort scores (0.89 vs. 1.33) compared with untrained students, but this did not reach statistical significance.

CONCLUSIONS

Our NM accurately simulates human texture and anatomy and provides an opportunity for endoscopic training without concern of bloodborne pathogens and expense of cadavers. Further development of the NM is warranted to expand the training utility.

Minimally invasive pediatric surgery: Our experience

Aim:

Departmental survey of the pediatric laparoscopic and thoracoscopic procedures.

Materials and Methods:

It is a retrospective study from January 1999 to December 2007. The various types of surgeries, number of patients, complications and conversions of laparoscopic and thoracoscopic procedures were analyzed.

Results:

The number of minimally invasive procedures that had been performed over the past 9 years is 734, out of which thoracoscopic procedures alone were 48. The majority of the surgeries were appendicectomy (31%), orchiopexy (19%) and diagnostic laparoscopy (16%). The other advanced procedures include laparoscopic-assisted anorectoplasty, surgery for Hirschprung’s disease, thoracosocpic decortication, congenital diaphragmatic hernia repair, nephrectomy, fundoplication, etc. Our complications are postoperative fever, bleeding, bile leak following choledochal cyst excision and pneumothorax following bronchogenic cyst excision. A case of empyema thorax following thoracoscopic decortication succumbed due to disseminated tuberculosis. Our conversion rate was around 5% in the years 1999 to 2001, which has come down to 3% over the past few years. Conversions were for sliding hiatus hernia, nephrectomy, perforated adherent appendicitis, Meckel’s diverticulum, thoracoscopic decortication and ileal perforation.

Conclusion:

The minimally invasive pediatric surgical technique is increasingly accepted world wide and the need for laparoscopic training has become essential in every teaching hospital. It has a lot of advantages, such as less pain, early return to school and scarlessness. Our conversion rate has come down from 5% to 3% with experience and now we do more advanced procedures with a lower complication rate.

The changing face of surgical education: simulation as the new paradigm

Surgical simulation has evolved considerably over the past two decades and now plays a major role in training efforts designed to foster the acquisition of new skills and knowledge outside of the clinical environment. Numerous driving forces have fueled this fundamental change in educational methods, including concerns over patient safety and the need to maximize efficiency within the context of limited work hours and clinical exposure. The importance of simulation has been recognized by the major stake-holders in surgical education, and the Residency Review Committee has mandated that all programs implement skills training curricula in 2008. Numerous issues now face educators who must use these novel training methods. It is important that these individuals have a solid understanding of content, development, research, and implementation aspects regarding simulation. This paper highlights presentations about these topics from a panel of experts convened at the 2008 Academic Surgical Congress.

Laparoscopic versus open abdominal surgery in children with sickle cell disease is associated with a shorter hospital stay

BACKGROUND

Limited information exists comparing the post-operative complication rate of laparoscopic or open abdominal surgeries in children with sickle cell disease (SCD). The primary objective of this study was to compare the outcomes in children with SCD who required laparoscopic or open abdominal surgery for a cholecystectomy or splenectomy.

PROCEDURE

We conducted a retrospective analysis of laparoscopic and open abdominal surgeries performed in children with SCD (ages 0-20 years) at two medical centers from 1984 to 2004. The primary outcome measures were the rates of post-operative pain and acute chest syndrome (ACS) episodes following laparoscopic or open abdominal surgery. The secondary outcome was length of hospital stay following surgery. We also examined the potential contribution of pre-operative (transfusion) and intra-operative factors (operating time, estimated blood loss, and end-operative temperature) to post-operative SCD-related complications.

RESULTS

A total of 140 cases were identified, 98 laparoscopic and 42 open. Episodes of post-operative pain and ACS episodes were comparable between laparoscopic and open procedures (pain: 4% vs. 3%, P = 0.619; ACS: 5% vs. 5%, P = 0.933). Additionally, laparoscopic surgeries were associated with a significantly shorter hospital stay (2.9 vs. 5.4 days, 95% CI -3.7 to -1.4, P < 0.001). There was no difference in the number of hospital readmissions within 1 month of the surgery.

CONCLUSIONS

For children with SCD who need a cholecystectomy or splenectomy, laparoscopy is the preferred strategy because of a shorter hospital stay with a similar complication rate compared to open surgeries.

The impact of haptic learning in telemanipulator-assisted surgery

BACKGROUND

The use of a telemanipulator requires special training and surgical performance is associated with a learning curve. The aim of this study was to demonstrate the potential value of Haptic-Visual over Visual-Only passive Training in telemanipulator-assisted surgery.

METHODS

Two telemanipulator consoles (da Vinci, Intuitive Surgical) were linked through an Application Programer's Interface allowing the applicant at the training console to register the position and passively follow the motions of the instructor's master telemanipulators (MTMs) at the master console (Haptic-Visual Learning group, HVL). The applicant could not actively interfere with the MTM movements. Both the trainee and the instructor shared the same 3-dimensional vision. Alternatively, subjects received only standard visual training without touching the MTMs (Visual-Only Learning group, VL). A standardized demonstration of tasks and the system was given for both groups. Participants (n=20) without previous experience with telemanipulation performed a set of various tasks in a randomized order. Study end points were time and accuracy required to perform the different task.

RESULTS

The first task, with moving items to appropriate locations, showed differences in time to perform the task [mean: 4:06 min (HVL) vs. 5:16 min (VL) (P=0.2)] and accuracy differed among groups [mean number of errors 1.7 (VL) vs. 1.3 (HVL) P=0.38]. With more challenging tasks [cut out round figures (cut) and performing double dot suture lines (sti)] the number of errors was less in the HVL group [mean: 1.1 errors (cut) (P=0.05) and 1.8 errors (sti) (P=0.26)] compared with the VL group [mean: 1.8 errors (cut) and 2.3 errors (sti)]. In addition, the time to perform the tasks decreased in the HVL group with mean: 5.42 minutes (cut) (P=0.26) and 9.41 minutes (sti) (P=0.36) compared with the VL group with mean: 7.09 minutes (cut) and 11.43 minutes (sti).

CONCLUSIONS

This study demonstrated the impact of haptic-visual passive learning in telemanipulator-assisted surgery which may alter the training for telemanipulator-assisted endoscopic procedures.

Minimally-invasive pediatric surgery in 2004: a survey including 50 German institutions

BACKGROUND

A survey on the practice of laparoscopic and thoracoscopic surgery in pediatric surgical departments in Germany is presented.

MATERIALS AND METHODS

A questionnaire was sent to all 71 pediatric surgical departments in Germany (population 82 million). Fifty institutions (70%) took part in the survey that mainly included data for the year 2004: spectrum of minimally invasive operations, quantity of procedures, conversions, major complications, number of performing surgeons and residents.

RESULTS

Laparoscopic techniques were used in 48 departments (96%) and thoracoscopic techniques in 37 (74%). The annual frequency of laparoscopies was less than 100 in 30 departments (62%) and more than 100 in 15 (31%). The number of thoracoscopies was less than 50 in 35 departments (73%) and more than 50 in 2 (4%). Appendectomy was offered in 45 (90%), varicocelectomy in 32 (64%), and Fowler-Stephens operation in 33 (66%). Twenty-one departments (42%) covered more advanced procedures such as laparoscopically assisted pull-through for Hirschsprung disease. Most demanding procedures such as laparoscopic choledochal cyst resection, duodeno-duodenostomy, heminephrectomy, or pyeloplasty were offered by 10 departments (20%). Minimally invasive surgery was performed by 1 surgeon (12%) in 6 institutions and by more than 5 surgeons (14%) in 7 institutions.

CONCLUSION

Minimally invasive techniques are increasingly accepted in most German pediatric surgical institutions for a wide range of indications. However, the number of departments offering major minimally invasive procedures remains limited.

Randomized controlled trial of virtual reality simulator training: transfer to live patients

BACKGROUND

New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients.

METHODS

A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments.

RESULTS

In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance.

CONCLUSIONS

Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement.

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies

BACKGROUND

Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices.

METHODS

Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors.

RESULTS

The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time.

CONCLUSIONS

The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident's first 10 laparoscopic cholecystectomies.

Construct validity of the LapSim: Can the LapSim virtual reality simulator distinguish between novices and experts?

BACKGROUND

Virtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden).

METHODS

Forty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer.

RESULTS

The higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters.

CONCLUSIONS

Our results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

Does a one-day course influence surgeon adoption of laparoscopic ventral herniorrhaphy?

BACKGROUND

New laparoscopic techniques introduced after residency have created a new teaching paradigm focused on animate courses and preceptor instruction. The aim of this study was to test the effectiveness of animate course instruction in teaching laparoscopic ventral hernia repair (LVHR), its success in relationship to the course participants' previous minimally invasive surgery experience, and the role of preceptors in adapting these techniques.

METHODS

Surgeons participating in a one-day LVHR course (lectures/animal laboratory) at the Carolinas Medical Center were surveyed concerning professional demographics, prior laparoscopic experience, and their performance of LVHR before and after the encounter. Standard statistics were used to determine significance (P<0.05).

RESULTS

Of the 234 surgeons attending a LVHR course between 1999 and 2004, 171 (73%) answered the survey. Mean follow-up after the course was 427 days (range: 34-1202 d). Mean age was 45.9 years (range: 28-67 y). Mean time since residency was 14.4 years (range: 0.5-37 y), and 106 (62%) had learned at least basic laparoscopy in residency. One hundred twenty-six (73.7%) were in private practice. Since the course, 122 (71.3%) had performed a LVHR. They had performed a total of 2049 LVHRs (mean: 16.5; range: 1-102) compared with 1098 open herniorrhaphies (mean: 9; range: 1-23). There was no difference between those performing and not performing LVHR or the number executed with respect to practice type (P=0.67), age (P=0.47), years in practice (P=0.19), or laparoscopic experience in residency (P=0.42). Fifty-four (32%) surgeons had been precepted, and all have since performed LVHR. Surgeons with advanced laparoscopic experience were more likely to perform LVHR compared with those with only laparoscopic cholecystectomy experience (87% versus 33%, P=0.02). Indeed, of those with only laparoscopic cholecystectomy experience who performed LVHR, 80% were precepted. In the subset of surgeons who had not yet performed LVHR, 28 intended to start, 17 requested assistance, and 4 planned not to begin.

CONCLUSIONS

A one-day course impacts surgeon practice patterns despite age or type of practice. Surgeons with advanced laparoscopic skills are more likely to perform LVHR. Most with limited experience will begin after working with a preceptor. Didactic instruction and a precepted experience may determine the future performance of advanced laparoscopy.

The learning curve for hand-assisted laparoscopic colectomy: a single surgeon’s experience

BACKGROUND

Surgical experience and outcomes for hand-assisted laparoscopic colectomy were evaluated to define a learning curve.

METHODS

This study included 60 patients who underwent hand-assisted laparoscopic colectomies performed by a single surgeon. They were analyzed as three consecutive equal groups: A, B, and C. Pearson's chi-square test and one-way analysis of variance (ANOVA) were used to compare differences in demographics and perioperative parameters. Operative times were analyzed to document the learning curve for the procedure.

RESULTS

There were no significant differences between the three groups in terms of age, sex, operative procedure, or comorbidity. Groups B and C showed significantly shorter operative times, significantly earlier recoveries of gastrointestinal function, less blood loss, and shorter hospital stays than group A. The incidence of operative complications was not significantly different among the three groups (35% vs 5% vs 15%; p = 0.07).

CONCLUSIONS

Approximately 21 to 25 cases were needed to achieve proficiency in this series.