Laparoscopic surgery: time for re-evaluation

Laparoscopic skills maintenance: a randomized trial of virtual reality and box trainer simulators

OBJECTIVE

A number of simulators have been developed to teach surgical trainees the basic skills required to effectively perform laparoscopic surgery; however, consideration needs to be given to how well the skills taught by these simulators are maintained over time. This study compared the maintenance of laparoscopic skills learned using box trainer and virtual reality simulators.

DESIGN

Participants were randomly allocated to be trained and assessed using either the Society of American Gastrointestinal Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) simulator or the Surgical Science virtual reality simulator. Once participants achieved a predetermined level of proficiency, they were assessed 1, 3, and 6 months later. At each assessment, participants were given 2 practice attempts and assessed on their third attempt.

SETTING

The study was conducted through the Simulated Surgical Skills Program that was held at the Royal Australasian College of Surgeons, Adelaide, Australia.

RESULTS

Overall, 26 participants (13 per group) completed the training and all follow-up assessments. There were no significant differences between simulation-trained cohorts for age, gender, training level, and the number of surgeries previously performed, observed, or assisted. Scores for the FLS-trained participants did not significantly change over the follow-up period. Scores for LapSim-trained participants significantly deteriorated at the first 2 follow-up points (1 and 3 months) (p < 0.050), but returned to be near initial levels by the final follow-up (6 months).

CONCLUSIONS

This research showed that basic laparoscopic skills learned using the FLS simulator were maintained more consistently than those learned on the LapSim simulator. However, by the final follow-up, both simulator-trained cohorts had skill levels that were not significantly different to those at proficiency after the initial training period.

Natural Orifice Trans-Luminal Endoscopic Surgery in the esophagus

As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.

Natural orifice translumenal endoscopic surgery (N.O.T.E.S)

Natural orifice translumenal endoscopic surgery (N.O.T.E.S) is a technique that allows access to the peritoneal cavity through natural orifices (oral, rectal, vaginal, vesical) without passing through the anterior abdominal wall. Rapid strides have been made in developing this technique, especially in animal models. Majority of research work in this field is originating from USA, while human clinical trials are being reported from India and Southern America. Morbidly obese patients and ITU patients are two target groups where N.O.T.E.S if implemented, will have the highest potential and bearing. With increasing evidence of safe practice in human models, questions on indications and feasibility of practice need to be addressed by rigorous research, strong evidence and collaboration between surgical centers worldwide.

A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting

OBJECTIVE

Evaluation of models, techniques, outcomes, pitfalls, and applicability to the clinical setting of natural orifice translumenal endoscopic surgery (NOTES) for performing intra-abdominal surgery through a systematic review of the literature.

SUMMARY BACKGROUND DATA

NOTES has attracted much recent attention for its potential to allow traditional surgical procedures to be performed entirely through a natural orifice. Amid the excitement for potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated.

METHODS

Studies were identified by searching MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Library, Entrez PubMed, Clinical Trials Database, National Health Services Centre for Reviews and Dissemination (NHS CRD) databases, and National Research Register from 2000 to June 2007. Studies identified in September 2007 were included if they were performed in live human subjects.

RESULTS

Of the 34 studies included for review, 30 were experimental studies conducted in animals, thus the evidence base was very limited. Although intra-abdominal access could be achieved reliably via oral, anal, or urethral orifices, the optimal access route and method could not be established. Viscerotomy closure could not be achieved reliably in all cases and risk of peritoneal infection has not been adequately minimized. Although the majority of interventions could be performed in animals using NOTES, a number of technical problems were encountered that need to be resolved.

CONCLUSIONS

NOTES is still in early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-managed human studies need to be conducted to determine the safety and efficacy of NOTES in a clinical setting.