Mental distress and effort to engage an image-guided navigation system in the surgical training of endoscopic sinus surgery: a prospective, randomised clinical trial

The use of image-guided navigation systems in the training of FESS is discussed controversy. Many experienced sinus surgeons report a better spatial orientation and an improved situational awareness intraoperatively. But many fear that the navigation system could be a disadvantage in the surgical training because of a higher mental demand and a possible loss of surgical skills. This clinical field study investigates mental and physical demands during transnasal surgery with and without the aid of a navigation system at an early stage in FESS training. Thirty-two endonasal sinus surgeries done by eight different trainee surgeons were included. After randomization, one side of each patient was operated by use of a navigation system, the other side without. During the whole surgery, the surgeons were connected to a biofeedback device measuring the heart rate, the heart rate variability, the respiratory frequency and the masticator EMG. Stress situations could be identified by an increase of the heart rate frequency and a decrease of the heart rate variability. The mental workload during a FESS procedure is high compared to the baseline before and after surgery. The mental workload level when using the navigation did not significantly differ from the side without using the navigation. Residents with more than 30 FESS procedures already done, showed a slightly decreased mental workload when using the navigation. An additional workload shift toward the navigation system could not be observed in any surgeon. Remarkable other stressors could be identified during this study: the behavior of the supervisor or the use of the 45° endoscope, other colleagues or students entering the theatre, poor vision due to bleeding and the preoperative waiting when measuring the baseline. The mental load of young surgeons in FESS surgery is tremendous. The application of a navigation system did not cause a higher mental workload or distress. The device showed a positive effort to engage for the trainees with more than 30 FESS procedures done. In this subgroup it even leads to decreased mental workload.

Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature

BACKGROUND

Gastroesophageal reflux disease (GERD) remains a significant problem for the medical community. Many endoluminal treatments for GERD have been developed with little success. Currently, transoral incisionless fundoplication (TIF) attempts to recreate a surgical fundoplication through placement of full-thickness polypropylene H-fasteners. This, the most recent procedure to gain FDA approval, has shown some promise in the early data. However, questions of its safety profile, efficacy, and durability remain.

METHODS

The Cochrane Library and MEDLINE through PubMed were searched to identify published studies reporting on subjective and objective GERD indices after TIF. The search was limited to human studies published in English from 2006 up to March 2012. Data collected included GERD-HRQL and RSI scores, PPI discontinuation and patient satisfaction rates, pH study metrics, complications, and treatment failures. Statistical analysis was performed with weighted t tests.

RESULTS

Titles and abstracts of 214 papers were initially reviewed. Fifteen studies were found to be eligible, reporting on over 550 procedures. Both GERD-HRQL scores (21.9 vs. 5.9, p < 0.0001) and RSI scores (24.5 vs. 5.4, p ≤ 0.0001) were significantly reduced after TIF. Overall patient satisfaction was 72 %. The overall rate of PPI discontinuation was 67 % across all studies, with a mean follow-up of 8.3 months. pH metrics were not consistently normalized. The major complication rate was 3.2 % and the failure rate was 7.2 % across all studies.

CONCLUSION

TIF appears to provide symptomatic relief with reasonable levels of patient satisfaction at short-term follow-up. A well-designed prospective clinical trial is needed to assess the effectiveness and durability of TIF as well as to identify the patient population that will benefit from this 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.

[Perception of natural orifice surgery. Results of a survey of female physicians and nursing staff]

BACKGROUND

Natural orifice surgery (NOS) is now being elaborated with the aim to make abdominal surgery simpler and safer. In order to obtain women's perception of NOS and their willingness to consent to this type of approach a survey was conducted among female employees from surgical disciplines at the University Hospital Charité Berlin.

MATERIAL AND METHODS

A written description and information on minimally invasive surgery and the NOS concept were distributed among 500 female physicians and nursing staff along with a 14-item questionnaire. Of the staff members 118 participants completed the questionnaire anonymously. Data analysis was carried out using SPSS 16.0.

RESULTS

With regard to ovarectomy 55% of women surveyed indicated that they would prefer a transvaginal approach to standard laparoscopy (44%) or a transgastric approach (1%). When asked about preferred access for cholecystectomy only 31% would prefer the transvaginal method compared to 61% for the laparoscopic technique. Objections against the transvaginal access concerned the impact on a healthy sexual life and effects on fertility. Reasons for choosing NOS were no wound pain and no scar.

CONCLUSION

This survey shows that among the surveyed female medical employees the transvaginal approach is associated with concerns and fears but these are not justifiable, as the transvaginal access has been used for more than 100 years for gynecological purposes. There is a strong need for outcome data to enlighten female patients and to help guide physicians when talking to patients regarding NOS and the transvaginal approach.

Public perception of LESS surgery and NOTES

INTRODUCTION

This study was undertaken to determine public attitudes toward laparoendoscopic single-site (LESS) surgery and natural orifice transluminal endoscopic surgery (NOTES) and to determine how they are impacted by age, gender, and obesity.

METHODS

One hundred fifty-two citizens completed a validated questionnaire. Pearson correlations were computed to determine relationships among items queried. Scores ranged from 1 (lowest) to 5 (highest) and are presented as median, mean ± SD.

RESULTS

The citizens generally liked their physique (4, 4 ± 1.0) and felt attractive (4, 4 ± 1.0). LESS surgery was appealing if it involved no more risk or recovery and none to minimally more pain, operative time, and cost. Older and heavier citizens were more interested in reduced risk, pain, and operative/recovery time and less interested in scarring/appearance. Thirty-nine percent would consider NOTES, though only with no more risk, pain, operative time, and cost (<$200). Older people regarded NOTES more favorably. Lack of scarring with NOTES was most important by only 32% of those participants that would consider undergoing a NOTES procedure.

CONCLUSION

Acceptance of LESS surgery and NOTES depends upon no additional risk and no or minimally increased pain, recovery time, and cost. Improved cosmesis is not generally a priority, particularly in older or heavier people. Safety, pain, and recovery time remain major issues in deciding operative choices.

The ergonomics of natural orifice translumenal endoscopic surgery (NOTES) navigation in terms of performance, stress, and cognitive behavior

BACKGROUND

The evolution toward minimally invasive surgery and subsequently to natural orifice translumenal endoscopic surgery (NOTES) poses challenges to the surgeon in terms of increased task complexity requiring greater visuospatial and navigational ability. Neuroergonomics is the study of the brain and behavior at work, and establishing the baseline cortical response for NOTES procedures will help to ascertain whether technological innovation such as navigational aids can alleviate the task-induced cognitive burden. The aims of the current study are to characterize the impact of navigation within a NOTES environment on the subject in terms of (1) performance, (2) stress, (3) prefrontal cortical activity, and (4) how this is influenced by expertise.

METHODS

In all, 29 subjects were assessed for performance, stress response, and prefrontal cortical activity during a NOTES navigational task within a validated NOTES simulator.

RESULTS

Experts performed significantly better than novices (P < .05). Expertise was not a predictor for overall changes in prefrontal cortical activity. The differences between experts and novices were modulated by the location of prefrontal cortical activity, with experts demonstrating more pronounced lateral prefrontal cortical activation compared with novices. Stress was not an independent predictor of changes in prefrontal cortical hemodynamics.

CONCLUSION

This study is the first to characterize the performance, stress, and neurocognitive behavior associated with natural orifice translumenal endoscopic surgery navigation. The results indicate the relevance of visuospatial centers in successful task execution, and they serve as a baseline within the neuroergonomic paradigm for investigating performance-enhancing technology.

Inpatients and specialists' opinions about natural orifice translumenal endoscopic surgery

In the last three years, investigations on natural orifice translumenal endoscopic surgery (NOTES) have entered the clinical experimental phase. Our aim was to carry out the first cross-sectional survey in Hungary about inpatients and specialists' opinions concerning natural orifice surgery. A total of 155 patients were included in the survey from two hospitals. Patients received a handout that described in detail the various available techniques for cholecystectomy, plus a 10-item questionnaire. Respondents had to choose between undergoing laparoscopic or NOTES cholecystectomy, indicate the acceptable complication rate, provide the reason for their choice, and select an ideal orifice. Specialists attending lectures on NOTES at two Hungarian congresses were given a separate questionnaire that was designed for physicians. We measured their perceptions about the need for the new method and about the unsolved issues it involved, their choice of entry site, their assessment of which type of specialist should perform NOTES operations, and the timeframe that would be needed for the widespread adoption of the method. With complication rates presumed to be equivalent to each other, 53% of inpatients chose a NOTES operation over laparoscopy for a cholecystectomy. Those who had prior endoscopy (p = 0.03), prior open surgery (p = 0.03), or who were male (p = 0.05) were more likely to opt for NOTES. The preferred approach was transvaginal (49%) for women, and transcolonic (66%) for men. Regarding the specialists, 37% would like to use NOTES in their practice and 49% would undergo a NOTES procedure; of these, 43% were unable to indicate the ideal orifice, 22% preferred the vagina, 20% the stomach, and 15% a hybrid approach. A total of 54% of surgeons believed that there is a real demand for NOTES, whereas 37% felt that it is an unnecessary innovation.

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique

BACKGROUND

Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES.

METHODS

This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified.

RESULTS

Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents.

CONCLUSIONS

Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.