Advanced Laparoscopic Procedures Research Articles

Laparoscopic right colectomy: correct technique based on key anatomical principles

Since the early1990s, laparoscopic right colon resections have been the most performed advanced laparoscopic procedures just after laparoscopic left colectomies and sigmoid resections. Indications for laparoscopic right colectomies are either benign or malignant diseases. Despite its many indications, a laparoscopic right or extended right colectomy is mostly performed for cancer of the caecum, the ascending colon, the hepatic flexure or the proximal transverse colon. Worldwide, colorectal cancer is the third most diagnosed cancer: an estimated 1,880,725 people were diagnosed with colorectal cancer in 2020, out of which 1,148,515 were colon cancer cases and 40% were located in the right colon. These figures make an oncologic sound surgery for right colon cancer of the utmost relevance. More recently, complete mesocolic excision has been advocated as the optimal choice in term of radicality, especially in node-positive patients with right colon cancer. Laparoscopic standard right colectomy and extended right colectomy with or without CME should be performed according to defined principles based on a close knowledge of key anatomical landmarks. This knowledge will allow to trace anatomical structures and drive instruments along the correct surgical planes and has its foundations in teachings from surgeons and scientists of past and present time.

Laparoscopic surgery: My Journey

For 35 years, there has been a rapid spread and evolution of laparoscopic surgery in the developed world, where this modality is now regarded as a safe and first choice for up to 98% of all surgical interventions by adequately trained surgeons. The advantages of laparoscopic surgery are now well established. Surgeons must be encouraged to undergo the required training to provide safe laparoscopic surgery. Having pursued my Master’s in Obstetrics and Gynecology at the University of Nairobi, I was posted to Kilifi District Hospital where I served for nine years. I later moved back to Mombasa and ventured into private practice. I developed an interest in and pioneered minimal access surgery in 1994. I developed an immense interest and passion in minimal access surgery and initially pursued a Diploma in Laparoscopic Surgery at the Coimbatore Institute of Gastrointestinal Endosurgery (CIGES). Subsequently, I attended dedicated workshops and additional training in Kiel, Hamburg (Germany), Clermont-Ferrand and Strasbourg (France), and various institutions in Asia and Europe, attending over 40 dedicated workshops, including advanced laparoscopic and hysteroscopic procedures. In 2000, I moved my practice to Nairobi and worked at various private institutions. To increase the awareness of laparoscopic surgery in Kenya. I organized workshops and encouraged many gynecologists and general surgeons to embrace change. I was later fortunate to be invited to several African countries where I trained and mentored numerous surgeons. In conclusion, laparoscopic surgery faces many challenges but is a safe and effective alternative to the traditional open modalities of surgery. The training of surgeons and support staff should be made a priority. I pray that my journey will be an inspiration and encouragement to many in our fraternity in the years ahead.

Association between BMI and Intraoperative Time and Length of Hospital Stay among Patients undergoing Laparoscopic Colorectal Surgery: A Retrospective Study

Introduction: Now-a-days, most surgeons are aware that obese patients face more difficulties during laparoscopic colorectal surgery compared to non obese patients, especially with the prevalence of advanced laparoscopic procedures. Aim: To investigate the association between Body Mass Index (BMI) and operative time, as well as the length of hospital stay after laparoscopic colorectal surgery. Materials and Methods: A retrospective observational study was conducted at Sri Guru Ram Das (SGRD) Charitable Hospital in Amritsar, Punjab, India, from January 2016 to January 2019. The study included 139 patients who underwent laparoscopic colorectal surgery. The dataset consisted of four variables: BMI (continuous), intraoperative time (continuous), diagnosis (nominal, including various diseases such as Crohn’s disease, colon cancer, ulcerative colitis, and diverticulitis), and length of stay (dichotomous, categorised as “yes” if the total length of stay in the hospital was greater than three days, and “no” if it was three days or under). Mean and standard deviations were calculated for both BMI and intraoperative time. The Pearson’s r correlation test was used to assess the association between BMI and intraoperative time. Results: A total of 139 patients were included in the study, with 72 (51.80%) having a length of stay less than three days and 67 (48.20%) having a length of stay greater than three days. Higher BMI was found to be associated with a prolonged length of stay (>three days) in the hospital following colorectal surgery, with a p-value of 0.007. However, the study did not find a statistically significant association between BMI and intraoperative time, with a p-value of 0.1795. Conclusion: Obese patients tend to spend a longer time in the hospital compared to non obese patients. Therefore, caution should be exercised when performing elective laparoscopic procedures on obese patients.

P-BN48 Utilising spatial geometry to obtain the ideal needle mount for laparoscopic intracorporeal suturing

Abstract Background Intracorporeal suturing is an essential component of any advanced laparoscopic procedure like fundoplication, bypass surgery or common bile duct exploration. Obtaining the appropriate needle mount during suturing can be challenging. Spatial geometry defines points in three-dimensional space. Ergonomics in laparoscopic surgery identifies a manipulation angle of 60o to target as being optimal. This knowledge, in combination with the principles of light reflection can be used to understand needle orientation in laparoscopic suturing. Methods An experiment was designed on a laparoscopic trainer with three participants. Using the principles of spatial geometry and light reflection, four different points were identified on an angle chart and labelled for a right-hand dominant participant as; centre, right off-centre (5.5cm), right lateral (10 cm) and left off-centre (5.5cm). Each participant was instructed to mount the needle at the defined points using light reflection on the needle shaft as a reference guide. Three readings were taken for each position. Mounted angle was defined as the angle between the shaft of needle holder and long axis of the needle. This was measured using a special application and an average value determined for each position. Results The average values for the mounted angle measurements for each spatial position were: Centre(112o), Right off centre(101o), Right lateral (88.8o) and Left off centre (124.6o). Conclusions This study describes a novel and reproducible technique to obtain an ideal needle mount. For a needle mount greater than 100o either the centre position or the left off-centre position should be considered.

Is Laparoscopic Technique Suitable for Initial Experience in Live Donor Nephrectomy? Results of The First 51 Cases

Objective: Laparoscopic donor nephrectomy is included in advanced laparoscopic surgical procedures and is the most preferred method for live donor nephrectomy. It is discussed that teams who do not have experience with live donor nephrectomy prefer the laparoscopic method for the first experience in kidney transplantation. The present manuscript is aimed to present the results of laparoscopic live donor nephrectomy who’s the first 51 cases of a surgical team without any experience of open donor nephrectomy. Method: The medical records of donor nephrectomy which laparoscopic surgery was performed between April 2019-August 2020 reviewed retrospectively. Demographic features, routine transplantation preoperative data, donor nephrectomy side and reasons, surgical technique details, operation time, warm ischemia time, postoperative laboratory parameters, hospitalization time, early morbidity results were evaluated in detail. Result: Results of 51 donors between the specified dates were evaluated. The mean age of the patients was 44.6 ± 11.6 (22-69) years. The patients’ K / E ratio was 25/26. The number of patients with BMI⩾30 was 14 (27.4%). Right nephrectomy was performed on ten donors (19.6%). The mean operative time of the patients was 130 min. (120-160), and the mean warm ischemia time was 149 sec. (113-180). Postoperative complications were in 4 patients (7.8%). Conclusion: The laparoscopic method for live donor nephrectomy may be applied in safe from the initial stage by teams with advanced minimally invasive surgery experience.

Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect?

The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques. A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012. The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year. The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.

Advance Laparoscopy in Minimal Resource Settings: Experience from a Public Sector Hospital in a Lower Middle Income Country

Background To share our experience of performing advanced laparoscopic procedures with minimal resources in a public sector hospital. Methods A retrospective study of laparoscopic cases performed from December 1st 2016 till Dec 31st 2020 was done. All the cases were done by single surgical unit but with different surgical teams both as elective as well as emergency procedure. Type of procedure, conversion to open, and immediate post operative complications and outcomes were recorded. Complications were recorded on the basis of the Clavian Dindo Classification. Results In 49 months a total of 1550 procedures were performed. 1133 basic and 417 advanced laparoscopic procedures were performed. Only advanced laparoscopic procedures are discussed further. Median patient aged was 33 years (Range 10 to 70 years). Male to female ratio was 1:1.2 (191:226). There was a conversion rate of 8.6% with 36 operations converted to open due to either technical issues or any complication. Median hospital stay was 2 to 12 days. Median operative time was 90minutes. Complications were seen in 48 patients. Grade 1/2 complications in 38 patients. Grade 3 complications were seen in 9 patients. Grade 4 in 1 patient. No Grade 5 (Mortality) complications were seen. Conclusions Advanced laparoscopic surgery can be safely undertaken in public sector hospitals in low resource countries with limited resources.

Advanced training in laparoscopic gastrointestinal surgical procedures using Genelyn®-embalmed human cadavers: A novel model.

Background:Human cadaver is ideal for learning and acquiring new surgical skills. While cadavers preserved using Thiel’s embalming method are commonly used for training in laparoscopic surgery, it is a cumbersome technique. We report our experience of using Genelyn®-embalmed cadavers for training in advanced laparoscopic gastrointestinal procedures.Materials and Methods:A cross-sectional satisfaction survey corresponding to level 1 of the Kirkpatrick model for training evaluation was performed among 19 participants of advanced laparoscopy surgical skills training workshop, in December 2019, using Genelyn®-embalmed cadavers. Visual, haptic and tactile characteristics of the organs and tissues were assessed along with overall satisfaction of the workshop using Likert scale.Results:Five Genelyn®-embalmed cadavers were used for the workshop. All the 19 participants perceived that the cadavers were odourless and allowed adequate insufflation for laparoscopic procedures. Most of the participants(n=16, 84%) agreed that the appearance and tactile fidelity of the solid organs, luminal structures and tissues in Genelyn®-embalmed cadavers were similar to that of a live patient. There was a strong agreement among participants that the workshop will help improve the laparoscopic skills(median Likert score–4).Conclusion:The participants of the surgical skill training workshop felt that the Genelyn®-embalmed cadavers were ideal for use in practicing advanced laparoscopic procedures.

The new pan-European post-specialty training curriculum in Paediatric and Adolescent Gynaecology

Interest in the field of Paediatric and Adolescent Gynaecology (PAG) has increased substantially over the last decade. Currently there is minimal consensus on how to interpret and validate professional experience, medical knowledge and surgical skills for doctors (accredited in Obstetrics and Gynaecology) who have an interest in and wish to achieve sub-specialisation in PAG. The challenge for the future of PAG is to create a framework of guidelines and references which in turn culminates in improvement and harmonisation in PAG healthcare delivery.The development of a post-specialty training curriculum in PAG for accredited practitioners was a logical next step after EBCOG introduced the PACT curriculum for OBGYN trainees. The guiding principle in the development of the PAG curriculum has been to strive for harmonisation in teaching and training in PAG within Europe. The new EURAPAG curriculum is divided in 17 chapters which in turn have been subdivided into medical and surgical sections plus a baseline skills section. The content has been determined through a consensus procedure amongst European gynaecologists and trainees. The medical chapters involve pathology that requires conservative treatment, prevention, education or lifestyle adjustment. The chapters that are both medical and surgical have a surgical (alternative) treatment ranging from vaginal procedures to advanced hysteroscopic and laparoscopic procedures and laparotomy.Currently, the framework for any medical education is workplace based competency training. Specific tools have been developed for workplace based assessments, such as direct observation (DO) of clinical task performance, Objective Structured Assessment of Technical Skills (OSATS), mini-clinical evaluation exercise (Mini-CEX) or case-based discussion (CBD). To measure progress in this PAG post-specialty training curriculum, the subspecialty trainee will be required to maintain and update a portfolio of experience and competency.

MINIMALLY INVASIVE TREATMENT OF OBSTRUCTIONS OF THE PYELOURETERAL SEGMENT IN NEONATES AND INFANTS. STATE OF THE ART

Introduction. The obstruction of pyeloureteral junction is the most common cause of hydronephrosis in neonates and infants. Indications for surgical treatment include: decrease in differentiated renal function less than 40%, continued decrease in differentiated renal function for more than 10% in subsequent examinations, poor excretory function at diuretic renography (T ½ more than 20 min), increase in the anteroposterior diameter of the pelvis over 20 mm or dilatation of degrees III and IV by the classification of the Society of Fetal Urology (SFU). Material and methods. Treatment options for this condition include a wide range of approaches - from active observation to minimally invasive methods, including laparoscopic or robotic pyeloplasty. The main goal of treatment is to alleviate symptoms as well as to improve and / or to maintain renal function. The most common technique for removing obstruction of the pyeloureteral junction is dismembered pyeloplasty which is also called Anderson-Hynes operation. The Anderson-Hynes laparoscopic pyeloplasty is not widely spread what reflects the complex nature of this surgery in newborns and infants. A surgical access aiming to provide a minimally invasive correction of the obstruction in the pelvic-ureteric junction can be achieved equally by laparoscopic pyeloplasty, retroperitoneoscopicpyeloplasty and robot-assisted laparoscopic pyeloplasty. Results. Currently, there is a limited number of reports on the application of laparoscopic techniques for treating pyeloureteral segment obstructions in newborns and infants. The reasonability of such an approach in children under one year of age remains a matter of debate. It has been found out that postoperative results after laparoscopy are similar to those after a conventional open intervention. Conclusion. This literature review demonstrates that a surgeon - before performing reconstructive operations on infant’s kidneys must have a good experience in many other advanced laparoscopic procedures with endosurgical suturing . Laparoscopy offers many more benefits than simply reducing the patient’s hospital stay or less drug use. The magnification inherent to high-definition (HD) or ultra-high-resolution television (UHD or 4K) technology makes these surgical interventions more accurate due to better visualization of such microobjects and their layers at the baby’s ureter, which has a diameter slightly exceeding 2 mm. Another advantage of laparoscopy lies in more adequate assessment of the situation in case of hydronephrosis than that in the open surgery.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Quality-based assessment of camera navigation skills for laparoscopic fundoplication.

Laparoscopic fundoplication is considered the gold standard surgical procedure for the treatment of symptomatic hiatus hernia. Studies on surgical performance in minimally invasive hiatus hernia repair have neglected the role of the camera assistant so far. The current study was designed to assess the applicability of the structured assessment of laparoscopic assistance skills (SALAS) score to laparoscopic fundoplication as an advanced and commonly performed laparoscopic upper GI procedure. Randomly selected laparoscopic fundoplications (n = 20) at a single institute were evaluated. Four trained reviewers independently assigned SALAS scoring based on synchronized video and voice recordings. The SALAS score (5-25 points) consists of five key aspects of laparoscopic camera navigation as previously described. Experience in camera assistance was defined as at least 100 assistances in complex laparoscopic procedures. Nine different surgical teams, consisting of five surgical residents, three fellows, and two attending physicians, were included. Experienced and inexperienced camera assistants were equally distributed (10/10). Construct validity was proven with a significant discrimination between experienced and inexperienced camera assistants for all reviewers (P < 0.05). The intraclass correlation coefficient of 0.897 demonstrates the score's low interrater variability. The total operation time decreases with increasing SALAS score, not reaching statistical significance. The applied SALAS score proves effective by discriminating between experienced and inexperienced camera assistants in an upper GI surgical procedure. This study demonstrates the applicability of the SALAS score to a more advanced laparoscopic procedure such as fundoplication enabling future investigations on the influence of camera navigation on surgical performance and operative outcome.

Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery

Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear. To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases. Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons. Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.

Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study.

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9min vs. 21.7 ± 6.2min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.

Outcomes of robotic surgery performed in patients with high BMI class: experience by a single surgeon.

Advanced laparoscopic procedures have been shown to be safe in patients with high Body Mass Index (BMI), but conversion rates remain high. This analysis aimed to evaluate the feasibility and clinical outcomes in terms of long- and short-term complications, pain relief of robotic surgery in morbidly obese patients. Patients with BMI class I-II-III with endometrial cancer or hyperplasia were treated with robotic hysterectomy (RH). Patients' characteristics, operating room time (OT), type of surgery, length of hospital stay, and incidence of complications were recorded. Records were reviewed for demographic data, medical/surgical history and comorbidities, perioperative findings and outcomes, as well as long-term complications and recurrences. Regarding stage, according to 2009 FIGO, 26 of cases were IA, while eight and five of cases were, respectively, IB, II stage. A total of 87 consecutive RH were analyzed. The more frequent comorbidity was hypertension. Twenty percent of the patients had multiple comorbidities (>2). The mean age was 63±10 years, with a mean BMI of 36±8.2 kg/m2. The more frequent BMI group treated was II class. The median OT was 114 minutes (range: 49-270). According to the Dindo Classification, there were no differences in major or minor complications between the 3 BMI classes. This series had a median follow-up of 60 months (range: 8-96) with an overall survival rate of 100%. The RRH+PLH was feasible and pathology confirmed the adequacy of the surgical specimen, with a median count of 20 nodes. Our data support the adoption of the surgical management of the morbidly obese patient. Although short term complication rates are higher with increasing obesity (II-III class), a majority of procedures can still be completed with minimally invasive approach.

1457 Laparoscopic Single Port Uterine Ovarian Ligament Plication and Ovarian Fixation

Video Objective To demonstrate the technique of ovarian fixation and uterine ovarian ligament plication using single port laparoscopy. Setting This is a 25 year old Gravida 0 who presents with a history of worsening left lower quadrant pain. Patient's history is significant for prior left ovarian torsion x 2 requiring laparoscopic intervention. Interventions This video demonstrates the first single port laparoscopic uteroovarian ligament plication and ovarian fixation using techniques in which the needle is positioned in different orientations to overcome limited angles of attack seen in single port surgery. The ovarian fixation is done in a way previously described in multiport laparoscopic surgery but not before in single port surgery. Novel knot tying techniques demonstrated as well. Conclusion Single port laparoscopy can be used in advanced laparoscopic procedures such as uteroovarian ligament plication and ovarian fixation.

Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

To compare the changes in hepatic enzymes and comfort level of the surgeon in low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPPLC, 7 mm Hg) with that of normal pressure pneumoperitoneum laparoscopic cholecystectomy (NPPLC, 14 mm Hg). Eighty-two patients were randomly divided into 2 groups (LPPLC and NPPLC). Serum levels of bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and lactate dehydrogenase were measured before the operation, at the time of reversal from anesthesia, 24 hours after the operation, and on day 7. Serious adverse events, intra-operative complications, surgeon's comfort level of dissection, operative time, conversion rates to an open procedure, or normal pressure pneumoperitoneum were recorded. Of the 41 patients randomized for LPPLC, 8 patients were converted to NPPLC due to difficulty in dissection and 1 converted to open in each group. There was statistically significant fall in mean serum bilirubin level in both the groups in the immediate postoperative period (P<0.05). Statistically significant increase in its level was observed after 24 hours in the NPPLC group only (P<0.05). Levels of mean serum serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactate dehydrogenase increased significantly (P<0.05) in immediate postoperative period and a further increase was observed after 24 hours (P<0.05) in the NPPLC group only. The comfort level of surgeon was found to be significantly better in the NPPLC group. LPPLC is a safe procedure, especially in the hands of an experienced surgeon with clinically insignificant systemic effects. But the comfort level of surgeon is better in normal pressure when compared with low pressure. In patients with deranged hepatic functions undergoing advanced laparoscopic procedures, it is advisable to start the surgery with low-pressure pneumoperitoneum. Pressure may be escalated further as per the surgeon's comfort.

Quality Improvement in Laparoscopic Donor Nephrectomy by Self-Imposed Proctored Preceptorship Model

Initiation of an advanced laparoscopic surgery program requires skill and proper training. Despite description of multiple surgical training modules, an ideal method for training of surgeons for advanced laparoscopic procedures is lacking. We propose an abbreviated self-imposed proctored preceptorship training model as the optimum training method for training skilled laparoscopic surgeons in advanced laparoscopic procedures like laparoscopic donor nephrectomy. The laparoscopic donor nephrectomy program was started at the Institute using preceptorship-proctorship model. One hundred left laparoscopic donor nephrectomies were performed over the course of 2 years. Outcomes in terms of performance related (Surgeon) outcomes in the form of learning curve and patient outcomes in terms of donor outcomes and recipient results and were studied. Learning curve was calculated using the moving average method and calculation of mean operative time of every five consecutive cases. Mean operative time for laparoscopic donor nephrectomy was 108.1 ± 26.5 min, the warm ischemia time averaged at 3.5 ± 1.3 min and the mean blood loss was 130.1 ± 54.9 ml. Moving average analysis revealed that approximately 20 LDN cases were needed to complete the learning phase. According to the mean operative time of every five consecutive cases, learning phase of LDN was completed between 26 and 30 cases. We believe that the abbreviated self-imposed proctored preceptorship model of training is an optimum model for starting a new advanced laparoscopic surgery program and can help surgeons to overcome the initial learning curve.

Self-directed training with e-learning using the first-person perspective for laparoscopic suturing and knot tying: a randomised controlled trial : Learning from the surgeon's real perspective.

Laparoscopic suturing and knot tying is essential for advanced laparoscopic procedures and requires training outside of the operating room. However, personal instruction by experienced surgeons is limitedly available. To address this, the concept of combining e-learning with practical training has become of interest. This study aims to investigate the influence of the first-person perspective in instructional videos, as well as the feasibility of a completely self-directed training curriculum for laparoscopic suturing and knot tying. Ninety-one laparoscopically naïve medical students were randomised into two groups training with e-learning videos in either the first-person perspective (combining endoscopic view and view of hands/instruments/forearm motion) or the endoscopic view only. Both groups trained laparoscopic suturing and knot tying in teams of two until reaching predefined proficiency levels. Blinded, trained raters regularly assessed the participants' performance by using validated checklists. After training, participants filled out questionnaires regarding training experience and personal characteristics. Average training time to reach proficiency did not differ between groups [first-person perspective (min): 112 ± 44; endoscopic view only (min): 109 ± 47; p = 0.746]. However, participants from both groups perceived the first-person perspective as useful for learning new laparoscopic skills. Both groups showed similar baseline performances and improved significantly after training [Objective Structured Assessment of Technical Skills (OSATS) (max. 37 points): first-person perspective: 30.3 ± 2.3; endoscopic view only: 30.8 ± 2.3]. All participants managed to reach proficiency, needing 8-43 attempts without differences between groups. Visuospatial abilities (mental rotation) seemed to enhance the learning curve. Modifying instructional videos to the first-person perspective did not translate into a better performance in this setting but was welcomed by participants. Completely self-directed training with the use of e-learning can be a feasible training approach to achieve technical proficiency in laparoscopic suturing and knot tying in a training setting.

Simulation platforms to assess laparoscopic suturing skills: a scoping review.

Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence." Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience,and various metrics). Consequences were not addressed in any of the studies. We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.