Population perception of surgical safety and body image trauma: a plea for scarless surgery?

Evaluation of public's perception of scar cosmesis after thyroidectomy: results of a survey of Turkish versus South Korean individuals

Purpose

Visible scars on the neck caused by thyroid surgery give rise to significant aesthetic, functional, and psychosocial problems. The objective of this study is to comparatively investigate the public perception of neck scar cosmesis in Turkish and South Korean populations.

Methods

This survey was prepared to collect participants' demographic and socioeconomic data and determine their perception of scar cosmesis on the neck and consisted of 15 questions. One thousand thirty-nine individuals who did not undergo thyroid surgery completed the survey. The P-values of <0.05 were deemed to indicate statistical significance.

Results

There were 1,039 respondents, of whom 525 (50.5%) were Turkish and 514 (49.5%) were South Korean. South Korean respondents stated that they would be significantly more uncomfortable with the thought of having a scar due to thyroid surgery, compared to the Turkish respondents (P < 0.001). The South Korean respondents stated that they would be significantly more concerned about the scar's length, thickness, and darkening color, compared to the Turkish respondents (P < 0.001 for all cases).

Conclusion

Patients' expectations, which are affected by various sociodemographic factors and cultural characteristics, are as important as the medical condition when deciding on the type of thyroid surgery. The study findings clearly indicated that the South Korean population would be significantly more uncomfortable with having a scar on the neck, compared to the Turkish population. Therefore, in selected cases, a scarless thyroidectomy approach, such as transoral endoscopic thyroidectomy, vestibular approach may be preferable for societies like South Korea.

Evaluation of Preference and Utility Measures for Transoral Thyroidectomy

BACKGROUND

Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy.

METHODS

In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises.

RESULTS

Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics.

CONCLUSION

Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients-in keeping with the current findings of this study.

Evaluation of extended thymectomy approaches based on residual fat tissue

OBJECTIVES

This study analysed the patterns of extraction ranges, characteristics, advantages and disadvantages of median sternotomy (MS) and subxiphoid (SX) approaches for extended thymectomy.

METHODS

This study included patients with anterior mediastinum tumour and myasthenia gravis who underwent extended thymectomy at our institution between 2015 and 2018. There were 5 MS and 6 SX extended thymectomy surgeries with the VINCENT software. On preoperative computed tomography, the thymus area and fat tissue surrounding the thymus, which were planned for extraction, were traced using VINCENT (Ver. 4.0). We then constructed three-dimensional images and calculated the volumes. Evaluation of the extended thymectomy approach based on the residual fat tissue was required to determine the area of extended thymectomy.

RESULTS

No significant differences in operation time (min) [SX: 197.3 ± 34.0, MS: 206.6 ± 91.4, drainage duration (days), SX: 2.2 ± 1.0, MS: 2.2 ± 0.4, hospital stay (days), SX: 11.8 ± 1.2, MS: 13.4 ± 2.1, residual rate (%), SX: 29.9 ± 17.5, MS: 58.7 ± 18.0 (P = 0.0519)] were observed between the 2 groups. Bleeding was significantly lower for SX than for MS. The residual rate was lower for SX than for MS.

CONCLUSIONS

Considering the amount of the residual fat tissue, the SX approach allows an adequate dissection area for extended thymectomy compared with the MS approach.

Optimal instrument length for transumbilical laparoendoscopic single site (U-LESS) surgery

The aim of our study was to recommend a novel method for measuring the distance from the umbilicus to intra-abdominal organs, as well as recommend an instrument length that would accommodate transumbilical laparoendoscopic single-site (U-LESS) surgeries to these areas. From CT scans of 50 men and 50 women, we calculated the distance from the umbilicus to 11 intra-abdominal points of interest using two triangles oriented perpendicular to each other. Using known lengths of the triangles, we used the Pythagorean theorem to calculate distances with and without insufflation. Distances were measured from the umbilicus to the xyphoid process, superior most aspect of the spleen, neck of the gallbladder, bifurcation of the descending aorta, adrenal glands, superior pole(s) of the kidneys, inferior most aspect of the inguinal canal, suprapubic margin, and the apex of the prostate (or female bladder neck). We found that an instrument working length of 43 cm would be sufficient to facilitate U-LESS surgery for all of our patients to each of the measured points of interest. The technique described in this paper serves as a useful method by which to measure the distance from the umbilicus to any intra-abdominal point of interest. These measurements would allow surgeons to correctly select instruments with adequate length when planning to perform U-LESS surgery.

Laparo-Endoscopic Single Site (LESS) cosmesis: Patients perception of body image distortion after LESS surgery

BACKGROUND

Relative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions.

METHODS

Patients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate.

RESULTS

881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m². 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern.

CONCLUSION

Preoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis.

Article Commentary: Hemostats, Sealants, and Adhesives: A Practical Guide for the Surgeon

Hemostats, sealants, and adhesives are useful adjuncts to modern surgical procedures. To maximize their benefit, a surgeon needs to understand the safety, efficacy, usability, and cost of these agents. To be truly added to a surgeon's own toolbox, the operator must also have knowledge of when and how to best use these materials. This commentary is designed to succinctly facilitate this understanding and knowledge. A nomenclature and classification system based on group, category, and class has been created to help with this process and is provided here. By using this system, materials consisting of similar design and for common indications can be compared. For example, in this system, the three functional groups are hemostats, sealants, and adhesives. The hemostats may be divided into four categories: mechanical, active, flowable, and fibrin sealant. These hemostat categories are further subdivided into generic classes based on the composition of the approved materials. Similarly, categories and classes are provided for sealants and adhesives. In this commentary, the salient points with respect to the characteristics of these agents are presented. A discussion of when these agents can be used in specific indications and how they may be applied to achieve the best results is also provided.

Single-port versus multiport laparoscopic surgery comparing long-term patient satisfaction and cosmetic outcome

Introduction

Several studies and meta-analysis showed Single-port or Single-incision laparoscopic surgery (SPL) to be superior over Multiport laparoscopic surgery (MPL) mainly in terms of postoperative pain and cosmetic result. But very little is known whether these results are only a short-term effect or are persistent on the long run after SPL. We therefore evaluated and compared long-term outcomes regarding cosmesis and chronic pain after SPL and MPL.

Methods

We conducted a comparative study with propensity score matching of all patients undergoing SPL or MPL between October 2008 and December 2013 in terms of postoperative cosmetic results and chronic pain. Follow-up data were obtained from mailed patient questionnaires and telephone interviews. Postoperative cosmesis was assessed using the patients overall scar opinion on a 10-point scale and the Patients scale of the standardized Patient and Observer Scar assessment scale (POSAS). Chronic pain was assessed by 10-point scales for abdominal and umbilical scar pain.

Results

A total of 280 patients were included in the study with 188 patients (67.1%) after SPL and 92 patients (32.9%) following MPL. 141 patients (50.4%) underwent a cholecystectomy and 139 patients (49.6%) underwent an appendectomy. The mean follow-up time was 61.1 ± 19.1 months. The mean wound satisfaction assed by the overall scar and the PSOAS Patients scale score of the patients showed no significant difference between MPL and SPL. Patients after SPL reported more overall complains than after MPL (8.7% vs. 2.5%, respectively), but without statistical significance (p = 0.321). Umbilical pain scores were comparable between the two groups (1.4 ± 1.0 vs. 1.4 ± 1.0, p = 0.831).

Conclusion

We found no difference in long-term cosmetic outcomes after SPL and MPL. Chronic pain at the umbilical incision site was comparable on the long run.

A Prospective Randomized Controlled Trial of Single-Port and Three-Port Laparoscopic Appendectomy in Children

Background: This study aimed to evaluate single-port laparoscopic appendectomy (SPLA) in comparison with three-port laparoscopic appendectomy (3PLA) in children about the extent of surgical trauma after SPLA and 3PLA measured by serum interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations. Materials and Methods: A total of 50 patients with a median age of 11.5 were randomized to two groups. Experts in both methods performed the surgeries. The decision on the type of planned surgery was randomly determined. Serum IL-6 and CRP levels were measured using an enzyme-linked immunosorbent assay before, and at 12 and 36 hours after surgery. Furthermore, we compared operating time, hospital stay, postoperative pain, and complication rates. Results: The operative time in the 3PLA group was shorter than that in the SPLA group (P < .05). Preoperative IL-6 levels were not different between the two groups, but the rise (pre- versus postoperative) of IL-6 in the SPLA group was remarkably higher when compared with the 3PLA group (P < .05). Similar results were obtained for CRP; basal serum CRP levels were not different between the two groups, but the rise of CRP in the 3PLA group was significantly lower compared with that in the SPLA group. During the first 12 hours postoperative, the SPLA patients reported more severe postoperative pain and longer inpatient opiate usage was noted that after 3-PLA. Only one SPLA case was converted to 3PLA. There were no conversions to open surgery. The length of hospital stay and complication rate were not different between the two groups. Conclusions: SPLA in children is associated with longer operative times, increased pain level, and more severe surgical trauma as measured by postoperative CRP and IL-6 levels in comparison with a 3PLA. The two approaches were comparable regarding the length of hospital stay and complication rate.

Official definitions for undesirable medical events : Are they correctly applied in medicine?

Background

In Austria, elaborate definitions exist for the undesirable medical events side effect, adverse event, complication and medical malpractice. We aimed at investigating whether the official definitions for the abovementioned terms can be understood by a sample population representing a cross-section of the Austrian population.

Methods

In this study 1021 Austrian citizens were interviewed. Demographic parameters (age, gender, occupation, level of education, monthly income, number of inhabitants at place of residence) were assessed. Participants were told the official definitions for complication, side effect, adverse event and medical malpractice and asked to select the correct definition for “complication”. The impact of sample characteristics on the ability to identify the correct definition was investigated.

Results

Of the participants 315 (31%) identified the correct definition of a complication. Almost the same number (n = 302, 30%; χ² for single samples: p = 0.087) falsely selected the definition for side effect. Significantly fewer (both p < 0.001) chose the definitions for adverse event (n = 220, 22%) and medical malpractice (n = 155, 15%). Only the respective state of origin showed significant influence on the probability of choosing the correct definition out of the four. The probability was highest in Vorarlberg (0.400) and lowest in Upper Austria (0.216, p < 0.001).

Conclusion

For the majority the present official definitions for undesirable medical events are too complex to understand. Simple definitions for undesirable medical events should be included into patient education.

Patient Perceptions of Minimally Invasive Versus Open Spine Surgery

STUDY DESIGN

Prospective questionnaire.

OBJECTIVE

To describe patient perceptions of minimally invasive spine (MIS) versus open surgery, and to determine which factors are most heavily considered by the patient when choosing between approaches.

SUMMARY OF BACKGROUND DATA

MIS surgery has increased in popularity due to proposed advantages in the perioperative and immediate postoperative periods. However, patient preferences and understanding with regard to the differences between MIS and open surgery have not been elucidated.

MATERIALS AND METHODS

An anonymous questionnaire consisting of 30 questions was administered to patients scheduled to see either an MIS surgeon or an open spine surgeon for a clinical evaluation from 2016 to 2017. Six questions asked about patient demographics and medical history. Nine questions asked respondents to rate the importance of several criteria when deciding between MIS and open surgery. In total, 15 multiple choice and free response questions asked respondents about their perceptions of MIS versus open surgery with regard to surgical and physician characteristics.

RESULTS

In total, 326 patients completed the survey. The 3 most important criteria for patients when choosing between open and MIS surgery were: long-term outcomes, surgeon's recommendation, and complication risk. When compared with MIS surgery, the majority of patients perceived open surgery to be more painful (83.8%), have increased complication risk (78.5%), have increased recovery time (89.3%), have increased costs (68.1%), and require heavier sedation (62.6%). If required to have spine surgery in the future, the majority of both patient groups would prefer a minimally invasive approach (80.0%).

CONCLUSIONS

Long-term outcomes, surgeon's recommendation, and complication risk were the most important criteria identified by patients when choosing between open and MIS surgery. Patients also perceived MIS surgery to have advantages over open surgery with regard to postoperative pain, complication risk, recovery time, cost, and anesthesia requirement. Most patients seem to prefer a minimally invasive approach to their treatment.

Patient Perceptions of Open, Laparoscopic, and Robotic Gynecological Surgeries

Objective. To investigate patient knowledge and attitudes toward surgical approaches in gynecology. Design. An anonymous Institutional Review Board (IRB) approved questionnaire survey. Patients/Setting. A total of 219 women seeking obstetrical and gynecological care in two offices affiliated with an academic medical center. Results. Thirty-four percent of the participants did not understand the difference between open and laparoscopic surgeries. 56% of the participants knew that laparoscopy is a better surgical approach for patients than open abdominal surgeries, while 37% thought that laparoscopy requires the surgeon to have a higher technical skill. 46% of the participants do not understand the difference between laparoscopic and robotic procedures. 67.5% of the participants did not know that the surgeon moves the robot's arms to perform the surgery. Higher educational level and/or history of previous abdominal surgeries were associated with the highest rates of answering all the questions correctly (p < 0.05), after controlling for age and race. Conclusions. A substantial percentage of patients do not understand the difference between various surgical approaches. Health care providers should not assume that their patients have an adequate understanding of their surgical options and accordingly should educate them about those options so they can make truly informed decisions.

Transoral endoscopic mediastinal surgery (TOEMS)-results of a first clinical study for scarless mediastinal lymph node biopsies

BACKGROUND

Video-assisted mediastinoscopy (VAM) represents the standard procedure for mediastinal lymph node biopsies. This operation results in a scar at prominent position at the anterior neck. Since there is a trend to less invasive procedures, natural orifice transluminal endoscopic surgery (NOTES) was introduced to different fields of surgery. Based on NOTES we developed a new approach for mediastinoscopy: transoral endoscopic mediastinal surgery (TOEMS). In previous studies using human cadavers and living pigs the feasibility of TOEMS was shown. It was unclear whether TOEMS could be safely applied in patients requiring mediastinal lymph node biopsies.

METHODS

We conducted a clinical phase I study recruiting ten patients with unclear mediastinal lymphadenopathy not resolved by prior bronchoscopy. All patients underwent TOEMS for mediastinal lymph node biopsy. The duration of the procedure and complications were monitored. In addition, all patients were examined for pain, swallowing dysfunction and sensation disturbance.

RESULTS

TOEMS was accomplished in eight patients. In two patients operation was converted to VAM due to technical problems. Mediastinal lymph nodes were dissected in all patients who finished with TOEMS. On average, two separate lymph stations were reached by TOEMS. Duration of the procedure was 159±22 min. Permanent palsy of the right recurrent laryngeal nerve was noticed in one patient postoperatively.

CONCLUSIONS

This is the first report for a human application of NOTES in thoracic surgery. In fact, transoral endoscopic surgery seems to be a feasible approach for mediastinal lymph node biopsies. Further studies are needed to show whether this procedure has an advantage over VAM in terms of pain, complications and accessibility of mediastinal lymph node stations.

Midcervical scar satisfaction in thyroidectomy patients

OBJECTIVES/HYPOTHESIS

Assess long-term patient satisfaction with conventional thyroidectomy scars and the impact of thyroidectomy scars on patient quality of life.

STUDY DESIGN

Validated survey administration and retrospective review of clinical and demographic data.

METHODS

Patients who underwent conventional thyroidectomy through years 2000 to 2010 were identified and administered the validated Patient Scar Assessment Questionnaire. Mean satisfaction, appearance and scar-consciousness scores were determined. Thirty-seven patients also measured the length of their current scar. Patient demographic and operative data were collected retrospectively from the medical record. Data were analyzed with one-way analysis of variance and independent samples t testing.

RESULTS

Sixty of 69 patients perceived the appearance of their scar to be "good" or "excellent." Sixty-three patients (91.3%) were satisfied with all scar outcomes; 67 (97.1%) were satisfied with the overall appearance of their scar. Mean total satisfaction score was 17.3 (<26 indicates a high level of satisfaction). Fifty-six (81.2%) were "not at all" self-conscious of their scar; 65 (94.2%) reported no attempt to hide their scar. Seven patients (10.1%) indicated any likelihood of pursuing scar revision. Females had significantly higher total satisfaction scores, consciousness scores, and satisfaction with appearance scores. The effect of perceived scar length was significant for scar-consciousness, not patient satisfaction.

CONCLUSIONS

The majority of patients were satisfied with their thyroidectomy scar appearance. Few patients reported a desire to hide the scar or pursue revision. Women were more likely to be dissatisfied than men. Length may play a role in scar consciousness.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:1247-1252, 2017.

Turkish surgeons' experiences and perception about single-incision laparoscopic surgery

OBJECTIVE

We aimed to show Turkish surgeons' current status of experience and perception about single-incision laparoscopic surgery.

MATERIAL AND METHODS

The experience and perception of general surgeons, who were members of the Turkish Surgical Association (3.5%, 116/3312), about single-incision laparoscopic surgery were analyzed according to demographic characteristics and a self-report questionnaire with the following four domains: surgeons' perception regarding the performance of single-incision laparoscopic surgery in their clinical practice; their experience of laparoscopic surgery; education, experience, and attitude for single-incision laparoscopic surgery; and the reason for performing/not performing single-incision laparoscopic surgery in their practice.

RESULTS

There were no significant factors affecting Turkish surgeons' preference of surgical approach. Although, most surgeons performing single-incision laparoscopic surgery were educated (72.2%), the dominant factor driven them to perform this surgery seemed to be personal achievement and satisfaction (57%). Most surgeons who did not perform single-incision laparoscopic surgery were not interested to do so and considered it unnecessary (62.1%). In addition, the need for special equipment and training were dominant barriers (61%).

CONCLUSION

It seems that Turkish surgeons' perception to perform single-incision laparoscopic surgery was more related to their personal achievement and satisfaction.

Impact of single-incision laparoscopic cholecystectomy (SILC) versus conventional laparoscopic cholecystectomy (CLC) procedures on surgeon stress and workload: a randomized controlled trial

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) may lead to higher patient satisfaction; however, SILC may expose the surgeon to increased workload. The goal of this study was to compare surgeon stress and workload between SILC and conventional laparoscopic cholecystectomy (CLC).

METHODS

During a double-blind randomized controlled trial comparing patient outcomes for SILC versus CLC (NCT0148943), surgeon workload was assessed by four measures: surgery task load index questionnaire (Surg-TLX), maximum heart rate, salivary cortisol level, and instruments usability survey. The maximum heart rate and salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, intraoperatively after the cystic duct was clipped, and at skin closure. After each procedure, the surgeon completed the Surg-TLX and an instrument usability survey. Student's t tests, Wilcoxon rank sum test, and Kruskal-Wallis nonparametric ANOVAs on the dependent variables by the technique (SILC vs. CLC) were performed with α = 0.05.

RESULTS

Twenty-three SILC and 25 CLC procedures were included in the intent-to-treat analysis. No significant differences were observed between SILC and CLC for patient demographics and procedure duration. SILC had significantly higher post-surgery surgeon maximum heart rates than CLC (p < 0.05). SILC also had significantly higher mean change in the maximum heart rate between during and post-procedure (p < 0.05) than CLC. Salivary cortisol level was significantly higher during SILC than CLC (p < 0.01). Awkward manipulation of the instruments and limited fine motions were reported significantly more frequently with SILC than CLC (p < 0.01). In the surgeon-reported Surg-TLX, subscale of physical demand was significantly more demanding for SILC than CLC (p < 0.05).

CONCLUSIONS

Surgeon heart rate, salivary cortisol level, instrument usability, and Surg-TLX ratings indicate that SILC is significantly more stressful and physically demanding than the CLC. Surgeon stress and workload may impact patients' outcomes; thus, ergonomic improvement on SILC is necessary.

Prospective assessment of trocar-specific morbidity in laparoscopy

BACKGROUND

The purpose of the present study was to challenge the hypothetical advantage of single port laparoscopy (SPL) over conventional laparoscopy by measuring prospectively the morbidity specifically related to conventional trocar sites (TS).

METHODS

From November 2010 to December 2011, 300 patients undergoing various laparoscopic procedures were enrolled. Patient, surgery, and trocar characteristics were recorded. We evaluated at three time points (in-hospital and at 1 and 6 months postoperatively) specifically for each TS, pain (Visual Analog Scale), morbidity (infection, hematoma, hernia), and cosmesis (Patient Scar Assessment Score; PSAS). Patients designated their "worst TS," and a composite endpoint "bad TS" was defined to include any adverse outcome at a TS.

RESULTS

We analyzed 1,074 TS. Follow-up was >90 %. Pain scores of >3/10 at 1 and 6 months postoperatively, were reported by 3 and 1 % of patients at the 5 mm TS and by 9 and 1 % at the larger TS, respectively (5 mm TS vs larger TS; p = 0.001). Pain was significantly lower for TS located in the lower abdomen than for the upper abdomen or the umbilicus (p = 0.001). The overall complication rate was <1 % and significantly lower for the 5 mm TS (hematoma p = 0.046; infection p = 0.0001). No hernia was found. The overall PSAS score was low and significantly lower for the 5 mm TS (p = 0.0001). Significant predictors of "bad TS" were larger TS (p = 0.001), umbilical position (p = 0.0001), emergency surgery (p = 0.0001), accidental trocar exit (p = 0.022), fascia closure (p = 0.006), and specimen extraction site (p = 0.0001).

CONCLUSIONS

Specific trocar morbidity is low and almost negligible for 5 mm trocars. The umbilicus appears to be an unfavorable TS.

Patient perceptions about laparoscopy at Komfo Anokye Teaching Hospital, Ghana

INTRODUCTION

Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it.

METHODS

A cross-sectional survey was conducted among patients attending specialist clinics at KATH.

RESULTS

1070 patients participated. Mean age was 40±15 years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45 years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients' willingness to pay more for laparoscopy.

CONCLUSION

Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure.

METHODS

From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension.

RESULTS

There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration.

CONCLUSION

Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

Population perception of surgical approach in minimally invasive surgery

INTRODUCTION

The aim of this study was to better understand the impact that public opinion might have on surgical approaches in urologic minimally invasive surgery (MIS).

METHODS

We collected surveys from 400 participants, including the general population (n = 220) and paramedical staff (n = 180). Participants were anonymous. The survey included 16 questions on the characteristics and preference for the surgical approach if a urologic MIS were performed on them.

RESULTS

The responders preferred the transumbilical approach (57.0%) to the subcostal approach (43.0%). In particular, the preference for a transumbilical approach was significantly higher in females (65.1% vs. 49.3%, p = 0.0014). Similarly, when participants were divided into two groups (<50 years and ≥50 years), the preference for the transumbilical approach was significantly higher in the younger group (60.8% vs. 48.0%, p = 0.0187). Logistic regression analysis revealed that preference for this approach was about 2 times more likely to rise in the females (p = 0.032).

CONCLUSIONS

Preference for the transumbilical approach was significantly higher young female respondents. This patient subset most values the cosmetic benefits of transumbilical approach in urologic MIS.

Coming to terms with the fact that the evidence for laparoscopic entry is as good as it gets

Entry to the peritoneal cavity for laparoscopic surgery is associated with defined morbidity, with all entry techniques associated with substantial complications. Debate over the safest entry technique has raged over the last 2 decades, and yet, we are no closer to arriving at a scientifically valid conclusion regarding technique superiority. With hundreds of thousands of patients required to perform adequately powered studies, it is unlikely that appropriately powered comparative studies could be undertaken. This review examines the risk of complications related to laparoscopic entry, current statements from examining bodies around the world, and the medicolegal ramifications of laparoscopic entry complications. Because of the numbers required for any complications study, with regard to arriving at an evidence-based decision for laparoscopic entry, we ask: is the current literature perhaps as good as it gets?

Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A case-control study comparing single-incision, transvaginal, and conventional laparoscopic technique for cholecystectomy

BACKGROUND

The aim of the present study was to compare the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC), single-port cholecystectomy (SPC), and conventional laparoscopic cholecystectomy (CLC). Recently, single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery have been developed as minimally invasive alternatives for CLC. Few comparative studies have been reported.

METHODS

Female patients with symptomatic gallstone disease who were treated in 2011 with SPC, TVC, or CLC were entered into a database. Patients were matched for age, body mass index, and previous abdominal surgery. After the operation all patients received a survey with questions about recovery, cosmesis, and body image.

RESULTS

A total of 90 patients, 30 in each group, were evaluated. Median operative time for CLC was significantly shorter (p < 0.001). There were no major complications. Length of hospital stay, postoperative pain, and postoperative complications were not significantly different. The results for cosmesis and body image after the transvaginal approach were significantly higher. None of the sexually active women observed postoperative dyspareunia.

CONCLUSIONS

Both SPC and TVC are feasible procedures when performed in selected patients. CLC is a faster procedure, but other clinical outcomes and complication rates were similar. SPC, and especially TVC, offer a better cosmetic result. Randomized trials are needed to specify the role of SPC and TVC in the treatment of patients with symptomatic gallstone disease.

Consumer demand for surgical innovation: a systematic review of public perception of NOTES

BACKGROUND

The full scope of benefits offered by NOTES over traditional laparoscopy, if any, is not yet fully clear. Perceived patient demand for truly "scarless surgery" is often referenced one of the driving factors in the continued development of this relatively new technique. The true scale of patient preference and demand for NOTES as a surgical technique is unknown. This review aims to summarise currently available literature on the topic of patient perceptions of NOTES to guide future development of the technique.

METHODS

A comprehensive search of PubMed and Web of Science electronic databases was performed on 1st Jan 2014. To be considered for inclusion, articles were required to assess and report the perception of NOTES in a sample of laypersons (patients or general public). The primary endpoint assessed was acceptance or preference rates expressed by patients for NOTES procedures. Reasons given for preference or rejection of NOTES were recorded, as well as preferred access routes and any predicting factors of NOTES acceptance.

RESULTS

Initial search returned 1,334 results, resulting in 15 articles included in final data synthesis. These polled a total of 4,420 subjects. Acceptance of NOTES ranged between 41 and 84 %. Compared to a laparoscopic approach, preference rates for NOTES ranged from 0 to 78 %. Reasons for preferring NOTES were largely centred on potentially reduced recovery time, complications (particularly with reference to hernias) and postoperative pain. Improved cosmesis also played a role, but was secondary to the above issues. Overall, study quality was poor.

CONCLUSIONS

This review suggests significant public interest in NOTES and scarless surgery in general. Further research and consideration of differences in public perceptions across regions, countries and cultures are required.

The voice of Holland: Dutch public and patient's opinion favours single-port laparoscopy

INTRODUCTION:

Single-port laparoscopy is prospected as the future of minimal invasive surgery. It is hypothesised to cause less post operative pain, with a shorter hospitalisation period and improved cosmetic results. Population- and patient-based opinion is important for the adaptation of new techniques. This study aimed to assess the opinion and perception of a healthy population and a patient population on single-port laparoscopy compared with conventional laparoscopy.

MATERIALS AND METHODS:

An anonymous 33-item questionnaire, describing conventional and single-port laparoscopy, was given to 101 patients and 104 healthy volunteers. The survey participants (median age 44 years; range 17-82 years) were asked questions about their personal situation and their expectations and perceptions of the two different surgical techniques; conventional multi-port laparoscopy and single-port laparoscopy.

RESULTS:

A total of 72% of the participants had never heard of single-port laparoscopy before. The most important concern in both groups was the risk of surgical complications. When complication risks remain similar, 80% prefers single-port laparoscopy to conventional laparoscopy. When the risk of complications increases from 1% to 10%, 43% of all participants prefer single-port laparoscopy. A total of 70% of the participants are prepared to receive treatment in another hospital if single-port surgery is not performed in their hometown hospital. The preference for single-port approach was higher in the female population.

CONCLUSION:

Although cure and safety remain the main concerns, the population and patients group have a favourable perception of single-port surgery. The impact of public opinion and patient perception towards innovative techniques is undeniable. If the safety of the two different procedures is similar, this study shows a positive attitude of both participant groups in favour of single-port laparoscopy. However, solid scientific proof for the safety and feasibility of this new surgical technique needs to be obtained before this procedure can be implemented into everyday practice.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

BACKGROUND

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

METHODS

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

RESULTS

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

CONCLUSION

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

An investigation for public acceptance of laparoendoscopic single-site surgery

Objective: Laparoendoscopic single-site surgery (LESS) is the latest innovation in minimally invasive surgery with unconfirmed advantages. The public perception of LESS is the basis of carrying out the surgery.

Methodology: Participants from the outpatient department were invited to rate, on a 5-point Likert scale, the important factors including scar, complications, cost, pain and hospital stay in choosing surgery. In addition, those who preferred LESS would continue to make their choices as the risks of LESS in above mentioned aspects rose.

Results: About 85% of the questionnaires were included in the analysis. Complication was the most important factor with an average score of 4.77±0.43, followed by pain (3.84±0.96), scar (3.57±1.17), cost (3.41±0.87) and hospital stay (3.04±0.86). Of the 196 participants, 132 (67%) preferred LESS with younger age (35.3±10.64 versus 40.4 ±9.6, P=0.001). Better cosmesis was the only factor that made the participants choose LESS (3.78±1.11 versus 3.13±1.19, P<0.005). Almost 90% of the participants could accept the hypothesis (incision length of 3.5cm, cost up to 120%, pain up to 120%, hospital stay of 5 days), while only 50% of participants could accept the risk of complications of 6%.

Conclusions: Complication is the most important factor that the public are concerned about in choosing surgery. LESS is preferred by young who care more concerned about the cosmesis, even with moderately elevated risks of extending incision and increasing hospital cost, postoperative pain and hospital stay.

Danish surgeons' views on minimally invasive surgery

BACKGROUND AND AIM

Advancements in minimally invasive surgery have led to increases in popularity of single-incision laparoscopic surgery (SILS) and natural orifice translumenal surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) due to their postulated benefits of better cosmesis, less pain, and quicker recovery. This questionnaire-based study investigated Danish surgeons' attitudes toward these new procedures.

SUBJECTS AND METHODS

A 26-item questionnaire was developed and distributed electronically via e-mail to a total of 1253 members of The Danish Society of Surgeons and The Danish Society of Young Surgeons.

RESULTS

In total, 352 (approximately 30%) surgeons completed the questionnaire, 54.4% were over 50 years of age, and 76.6% were men. When choosing surgery, the most important factors taken into consideration were the risk of complication and short convalescence, whereas the least important factors were cosmesis and option of local anaesthesia. If the surgeons themselves were to undergo cholecystectomy, 35.5% would choose SILS, and 14.5% would choose NOTES provided that the risk was equal to traditional laparoscopy (3%). The fraction of surgeons willing to learn SILS and NOTES was 44.6% and 32.7%, respectively. The desire to learn was higher among less experienced and surgically active surgeons. Of the responders, 68.8% considered SILS and 43.2% considered NOTES would become standard techniques for cholecystectomy within 6 years.

CONCLUSIONS

The importance of risk of complications has not surprisingly a high priority among surgeons in this questionnaire. Why this is has to be investigated further before implementing SILS and NOTES as standard of care.

Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients

BACKGROUND

The aim of this study was to compare single-port access cholecystectomy (SPA) with the standard laparoscopic technique (LC) regarding the duration of the operation, complications, learning curve, late postoperative quality of life (QoL) and the incidence of incisional hernias.

METHODS

Between June 2009 and December 2011, a total of 122 SPA cholecystectomies were performed in our hospital. Simultaneously, 310 patients were operated on with the LC technique. In the LC group, 100 patients met the same criteria defined for SPA surgery. The two groups (SPA and LC) were compared by multivariable regression analysis. Endpoints of this study were quality of life (QoL) after 6 months by the EQ-5D questionnaire 5L and the incidence of incisional hernia 1 year after surgery. Operating time, hospital stay, and perioperative complications were also measured and compared. The median follow-up was 9.2 months (3-25 months).

RESULTS

The patients in the SPA group were younger and more often female. The mean operating time for group SPA was 73 min (35-136 min)-significantly longer than that for group LC with 60 min (33-190 min) (p < 0.001). Additional trocars were used in 8 of 122 (6.5 %) SPA patients. A conversion to open cholecystectomy was not necessary in SPA patients. The conversion rate in the LC group to open cholecystectomy was 2 % (2/100). The perioperative and postoperative complications and incisional hernia (5.5 %) were the same in both groups. QoL was significantly better in the SPA group in terms of mobility (p = 0,002), usual activity (p = 0.036), and overall anxiety (p = 0.026).

CONCLUSIONS

SPA cholecystectomy is safe, although the operation is significantly longer. No differences in terms of major complications or the incidence of incisional hernia were seen after 1 year. QoL was significantly better in patients operated on with the SPA technique.

Low COST surgery setting for one-operational port laparoscopic hysterectomy surgery with ordinary laparoscopic instruments: preliminary results

Background

Hysterectomy dates back to 120BC and is the second most commonly performed gynecological surgery in the world. Cosmetic demands and the necessity of rapid return to work have contributed to the minimally invasive laparoscopic approach for hysterectomy. The majority of reports describe the use of three or four incisions to perform the surgery (two or three for manipulation and one for optics).

Methods

This work describes our experience with using only two ports for 11 patients who underwent video-laparoscopic hysterectomy surgery. One port was used for the optical system, and the second was used for manipulation. Early and late surgery complications, as well as the time to return to work and daily activities, were assessed.

Results

The mean age of the patients was 41.4 years old (range 16 to 52 years) and the mean uterine weight was 133.54 g, ranging from 35 g and 291 g. The operative time ranged from 30 to 60 minutes (average 46.4 minutes) and the hospital stay ranged between 24 and 48 hrs. No intraoperative complications occurred, and no early or late postoperative complications were recorded. Patients reported minimal pain during the first 24–48 hrs in the hospital. Patients returned to their daily activities within seven days after surgery. Clinical care follow-up continued until the 40th postoperative day.

Conclusion

The laparoscopic hysterectomy technique with a single port for manipulation is a feasible procedure when the uterine weight is not greater than 400 mg with little postoperative pain. The patients had an early return-to-work and daily activities and a better cosmetic outcome. These preliminary data led us to make the one-operative port laparoscopic hysterectomy the procedure of choice for patients with a low uterine weight.

Mechanical evaluation of three access devices for laparoendoscopic single-site surgery

BACKGROUND

Many access devices have been developed for laparoendoscopic single-site surgery (LESS) during recent years. However, investigations are needed to determine which port is most suitable for this relatively new technique. The aim of this study was to evaluate commonly used ports using mechanical approaches in a training simulator. Any port that required less force and shorter surgery times had superior maneuverability.

METHODS

The following three commercially available access devices were evaluated: Multi-ports, TriPort, and single-incision laparoscopic surgery (SILS) Port. A LESS mechanical evaluation platform was developed to investigate the forces that acted on the instruments in the ports while moving along horizontal and vertical axes. In addition, a strain-force measurement system was used to compare the average load on the ports when performing standard maneuvers. Additionally, the task completion time was recorded when the maneuvers in these ports were completed.

RESULTS

During the horizontal displacement of the instrument, the traction forces of the Multi-ports were lower than those of the SILS Port, which were lower than those of the TriPort. The average traction forces were significantly different in pairwise multiple comparisons (P < 0.05). When the instrument was inserted into the ports, the vertical friction forces of the Multi-ports were the lowest and those of the TriPort were the highest. On extraction of the instrument, the friction forces of the Multi-ports remained the lowest, followed by those of the TriPort and SILS Port. There were statistically significant results among all the devices (P < 0.05). The average load required to perform the task was less for the SILS Port than that for the TriPort (P < 0.05). Similarly, the average load for the Multi-ports was significantly less than that for the TriPort (P < 0.001). The participants who used the Multi-ports had significantly faster task times than those who used the SILS Port or TriPort (P < 0.005).

CONCLUSIONS

Compared with the TriPort and SILS Port, the Multi-ports was associated with the least average load and the shortest task performance times in a training simulator. This study demonstrates that the Multi-ports may offer superior maneuverability for LESS.

Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies

PURPOSE

To assess the surgical efficacy and potential advantages of laparoendoscopic single-site adrenalectomy (LESS-AD) compared with conventional laparoscopic adrenalectomy (CL-AD) based on published literature.

METHODS

An online systematic search in electronic databasesM including Pubmed, Embase, and the Cochrane Library, as well as manual bibliography searches were performed. All studies that compared LESS-AD with CL-AD were included. The outcome measures were the patient demographics, tumor size, blood loss, operative time, time to resumption of oral intake, hospital stay, postoperative pain, cosmesis satisfaction score, rates of complication, conversion, and transfusion. A meta-analysis of the results was conducted.

RESULTS

A total of 443 patients were included: 171 patients in the LESS-AD group and 272 patients in the CL-AD group (nine studies). There was no significant difference between the two groups in any of the demographic parameters expect for lesion size (age: P=0.24; sex: P=0.35; body mass index: P=0.79; laterality: P=0.76; size: P=0.002). There was no significant difference in estimated blood loss, time to oral intake resumption, and length of stay between the two groups. The LESS-AD patients had a significantly lower postoperative visual analog pain score compared with the CL-AD group, but a longer operative time was noted. Both groups had a comparable cosmetic satisfaction score. The two groups had a comparable rate of complication, conversion, and transfusion.

CONCLUSIONS

In early experience, LESS-AD appears to be a safe and feasible alternative to its conventional laparoscopic counterpart with decreased postoperative pain noted, albeit with a longer operative time. As a promising and emerging minimally invasive technique, however, the current evidence has not verified other potential advantages (ie, cosmesis, recovery time, convalescence, port-related complications, etc.) of LESS-AD.

Single and multiple incision laparoscopic adjustable gastric banding: a matched comparison

BACKGROUND

Single incision laparoscopic bariatric surgery has developed over the last few years, with single incision laparoscopic adjustable gastric banding (SILS-AGB) being performed most commonly. However, there are no randomised controlled trials and few matched studies comparing SILS-AGB to conventional laparoscopic multi-port multiport adjustable gastric banding (LAGB). Our aim was to study any differences in outcome and analgesic requirements between two matched groups of gastric band patients (SILS-AGB and LAGB).

METHODS

Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients were matched for age, sex, weight, BMI and co-morbidities. Forty six SILS-AGB and LAGB patients were included for analysis. Their outcomes were compared for operating times, conversions, analgesia requirements, morbidity and mortality.

RESULTS

Patients characteristics between the SILS-AGB and LAGB groups were similar with no differences in their median age (44 vs 47 years), sex (m:f; 7:39 vs 4:42), body mass index (43.1 vs 44.4 kg/m(2)) or co morbidities respectively. In the SILS-AGB group the median operating time (70 min) was not significantly longer than in LAGB group (61.5 min, p = 0.07). However, SILS-AGB patients used less opiates (p < 0.01) than the LAGB patients. There was no difference in morbidity, mortality or readmission rates.

CONCLUSION

SILS-AGB is a safe and feasible option and is comparable with LAGB. Post operative demand for analgesia was significantly less in the SILS-AGB group. Further comparisons of post operative pain and long term outcomes are required; however preliminary results are promising.

Single-port laparoscopic cholecystectomy versus standard multiport laparoscopic cholecystectomy: a case-control study comparing the long-term quality of life and body image

PURPOSE

To study the postoperative quality of life and body image of patients who underwent either single-port cholecystectomy (SPC) or standard multiport laparoscopic cholecystectomy (SMLC) in a long-term assessment.

METHODS

Fifty patients who underwent SPC using the reusable X-Cone™ Laparoscopic Device were compared with a matched group (age, sex, body mass index) of 50 patients after SMLC. The health-related quality of life (HRQOL) and body image at 17 months postoperatively (median, range 9-23) was analysed by means of the Short-Form 12 Health Survey and the Body Image Questionnaire, respectively.

RESULTS

Both patient groups had comparable baseline characteristics, clinical courses, and postoperative complication rates. SPC patients were significantly more satisfied with the cosmetic result of their scar at 17 months postoperatively, in comparison to SMLC patients (cosmetic scale: 22.6 ± 2.8 vs. 19.5 ± 3.7, p < 0.001). However, the HRQOL did not differ between the SPC and SMLC patients (physical component scale: 50.0 ± 8.9 vs. 48.8 ± 9.4, p = 0.48; mental component scale: 53.8 ± 6.5 vs. 51.3 ± 8.5, p = 0.10).

CONCLUSION

Although the overall postoperative HRQOL was comparable, this study suggests that the cosmetic result of SPC after complete wound healing is superior to the standard multiport laparoscopic procedure.

Patient perception of natural orifice transluminal endoscopic surgery in an endoscopy screening program in Korea

PURPOSE

Natural orifice transluminal endoscopic surgery (NOTES) is a new method of accessing intracavitary organs in order to minimize pain by avoiding incisions in the body wall. The aim of this study is to determine patients' acceptance of NOTES in Korea and to compare their views about laparoscopic surgery and NOTES for benign and malignant diseases.

MATERIALS AND METHODS

The target number of total subjects was calculated to be 540. The subjects were classified into 18 sub-groups based on age groups, gender, and history of prior surgery. The questionnaire elicited information about demographic characteristics, medical check-ups, diseases, endoscopic and surgical histories, marital status and childbirth, the acceptance of NOTES, and the preferred routes for NOTES. In addition, the subjects chose laparoscopic surgery or NOTES for a hypothetical cholecystectomy and rectal cancer surgery, and responded to questions regarding the acceptable complication rate of NOTES, the appropriate cost of NOTES, and the reason(s) why they did not select NOTES.

RESULTS

486 of 540 patients (90.0%) who agreed to participate in this study completed the questionnaire. NOTES was preferred by the following patients: elderly; a history of treatment due to a disease; having regular check-ups; and a history of an endoscopic procedure (p<0.05). The most preferred route for NOTES was the stomach (67.1%). Eighty-four percent of the patients choosing NOTES responded that the complication rate of the new surgical method should be the same or lower than laparoscopic surgery. Vague anxiety over a new surgical method was the most common reason why NOTES was not selected in benign and malignant diseases (64% and 73%), respectively.

CONCLUSION

Patients appear to be interested in the potential benefits of NOTES and would embrace it if their concerns about safety are met. We believe that qualified surgical endoscopists can meet these safety concerns, and that NOTES development has the potential to flourish.

Mini-laparoscopy, laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery-assisted laparoscopy: novice surgeons' performance and perception in a porcine nephrectomy model

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Over the last few years, minimally invasive urological surgery has evolved towards less invasive, 'scarless' procedures. New surgical concepts, such as those of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been introduced. Mini-laparoscopy has been rediscovered in an attempt to reduce the invasiveness of standard laparoscopy. This study is the first to compare the perception of surgeons when first facing three different scarless options for performing a porcine nephrectomy and when dealing with the constraints of each technique. The study findings suggest that: (i) when first approaching these techniques, surgeons tend to perform equally well under expert guidance in the porcine model; (ii) mini-laparoscopy is perceived as less difficult to perform; (iii) for all the techniques, surgeon's impressions are in line with their expectations.

OBJECTIVE

• To evaluate the perception and performance of urological surgeons when first applying scarless surgical techniques.

METHODS

• The study was conducted during the 2(nd) Minimally Invasive Urological Surgical Week annual course in Braga, Portugal. • Fourteen attendees performed three porcine nephrectomies by using each of the following techniques: mini-laparoscopy, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopy. • Peri-operative data were recorded, and operating performance was scored by one experienced surgeon for each working station, using a global rating scale. • The surgeons' subjective perceptions of degree of difficulty were graded and their expectations before the procedures were recorded.

RESULTS

• Forty-two porcine nephrectomies were performed. • There were no differences in overall operating time, or time to dissect and manage the renal vascular hilum, whereas time to gain access was faster for LESS than for mini-laparoscopy or NOTES-assisted laparoscopy (mean [sd] 8 [6] min vs 10.2 [5.3] min vs 9.9 [5.3] min, respectively; P = 0.59). • A better visualization of the surgical field was obtained with mini-laparoscopy and there was a higher degree of difficulty of bimanual dexterity for LESS, but no significant differences were found among the three techniques for any variable (operating field view: P = 0.52; bimanual dexterity: P = 0.49; efficiency: P = 0.77; tissue handling: P = 0.61; autonomy: P = 0.2). • Subjective perception of the degree of difficulty trended in favour of mini-laparoscopy (P= 0.17), but no significant difference was found in terms of surgeons' impression as compared with their expectations (P = 0.34).

CONCLUSIONS

• When first approaching new scarless techniques, surgeons tend to perform equally well under expert guidance in the porcine model. • Mini-laparoscopy is perceived as less difficult to perform and, for all the techniques, surgeons' impressions are in line with their expectations.

Obese women's perception of bariatric trans-vaginal NOTES

Much of the discussion pertaining to natural orifice transluminal endoscopic surgery (NOTES) focuses on technical issues, with little attention to women's perception and to their willingness to consent to this surgery, especially in the field of obesity. Aim of this study was to evaluate obese women's perception of NOTES and trans-vaginal access. Sixty two obese patients undergoing bariatric surgery were given a written description of NOTES with an anonymous questionnaire exploring their concerns and opinions regarding this technique. The risk of complications was the most important aspect with regard to surgical procedures for 87.1% of patients, while the aesthetic result counted only for 16.1%; none of the patients would accept an increased risk of surgical complications for a better aesthetic result, and 74.2% of them would prefer a standardized traditional surgical approach. Nulliparous women were more concerned about the potentially negative effects of NOTES on fertility than multiparous women and younger women were more worried about the effects on sexual function than older women. 83.9% of patients refusing NOTES stated that the main reason for their refusal was the lack of definitive data on the beneficial effects. Bariatric NOTES potentially offers obese women a scarless intervention, but only a few obese women expressed worries about the cosmetic/aesthetic effects of surgery, while most of them were worried about effects on future fertility and sexual life. Our study highlights a strong need for early reporting of outcome data to enlighten patients about this new approach to bariatric surgery.

[Technology or technolatry: where are surgeons going?]

Innovative pressure forms part of the current technical-scientific utopia and equally affects surgeons, patients, communication media, and the health industry. It has brought a new type of technical adventurism with its accompanying iatrogenesis, which involves unnecessary risks. Personal ambitions, industrial persuasion and the promotion of hospital brands, both public and private, have weakened values and professional ethics in an environment in which technology is losing cost/benefit, and the conflict of interests have aroused many suspicions. A critical review of the technolatry culture is presented as well as a sober assessment of the costs of our interventions, not only in the economic sphere, but also as regards the safety of our patients, the environmental sustainability, and the most efficient use of health care devices.