Experience In Open Surgery Research Articles

Current surgical training: simultaneous training in open and laparoscopic surgery

Current surgical training: simultaneous training in open and laparoscopic surgery

Impact of established skills in open surgery on the proficiency gain process for laparoscopic surgery

Laparoscopic training traditionally follows open surgical training. This study aimed to investigate the impact of experience in open surgery on the laparoscopic proficiency gain process. A survey form investigating the importance of open experience before the start of laparoscopic training was sent to surgical experts and trainees in the United Kingdom. A separate experimental study objectively assessed the effects of open experience on laparoscopic skill acquisition using a virtual reality simulator. In the study, 11 medical students with no prior surgical experience (group A) and 14 surgical trainees with open but no laparoscopic experience in (group B) performed 250 simulated laparoscopic cholecystectomies. Psychomotor skills were evaluated by motion analysis and video-based global rating scores. Before the first and after the fifth and tenth operation, knowledge of laparoscopic techniques was assessed by a written test and by self-reported confidence levels indicated on a questionnaire. The 80 experts and 282 trainees who responded to the survey believed prior open experience aids confidence levels, knowledge, and skills acquisition. In the simulation study, no intergroup difference was found for any parameter after the first procedure. Group B scored significantly higher in the laparoscopic knowledge test before training began (42.7% vs. 64.3%; p = 0.002), but no significant difference was found after five operations. The two groups did not differ significantly in terms of confidence. Group B had a significantly shorter total operation time only at the first operation (2,305.6 s vs. 1,884.6 s; p = 0.037). No significant intergroup difference in path length, number of movements, or video-based global rating scores was observed. Prior open experience does not aid the laparoscopic learning process, as demonstrated in a simulated setting. Given the wealth of evidence demonstrating translation of virtual skills to the operating theater, we propose that the safe and effective introduction of well-supervised laparoscopic training may be possible at the beginning of a surgical training curriculum.

Laparoscopic surgery for adrenal tumors. A retrospective analysis

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. The aim of this study was to evaluate the short- and long-term results of 100 consecutive laparoscopic and open adrenalectomies performed during a period of 8.5 years in our Surgical Unit. A retrospective analysis of patients operated on for adrenal tumors was conducted. From May 1997 to August 2005, one hundred adrenalectomies were performed on 95 patients. Five patients underwent either synchronous or metachronous bilateral adrenalectomy. There were 38 men and 57 women, aged 16 to 80 years. The size of tumors in our series ranged from 3.2 to 27 cm. The largest laparoscopically excised tumor was a ganglioneuroma with a diameter of 13 cm. In 73 patients laparoscopic procedure was completed successfully. In 8 cases the laparoscopic procedure was converted to open. Fourteen patients were treated with open approach. One patient with pheochromocytoma succumbed following pulmonary embolus. In one patient with morbid obesity, Cushing's syndrome, and bilateral adrenal macronodular hyperplasia, the left laparoscopic adrenalectomy was complicated by a low output pancreatic fistula, conservatively treated. All other patients had an uneventful course. Operative time for laparoscopic adrenalectomies ranged from 65 to 180 minutes. The average postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 to 2 days (1.5 days), versus 5 to 20 days for patients who underwent open or converted procedure. Laparoscopic adrenalectomy should be the treatment of choice for all benign adrenal tumors. Laparoscopic resection of large adrenal tumors necessitates experience in open surgery and advanced laparoscopic surgery.

Modular Training for Residents with no Prior Experience with Open Pelvic Surgery in Endoscopic Extraperitoneal Radical Prostatectomy

PurposeTo establish a teaching program for the performance of endoscopic extraperitoneal radical prostatectomy (EERPE) that would ascertain the safe and efficacious training of residents with no previous experience with open pelvic surgery. Materials and methodsThe technique of EERPE was divided in 12 segments with 5 levels of difficulty. We thus designed a training program, where the resident learned the procedure in a mentor-defined schedule. During each educational EERPE, the trainee only performed the operative steps corresponding to his acquired skill level. The mentor performed the remaining parts of the EERPE, with the trainee assisting. The first 50 and consequent 100 cases performed by the residents were compared to the first 50 and last 100 cases (cases 521–621) performed by the mentor. ResultsTwo residents with no prior experience with open pelvic surgery participated in the study, and required 43 and 38 procedures respectively, until they were considered to be competent. The initial 50 procedures performed completely independently by the residents had mean operative times of 176 and 173minutes. There were 2 intraoperative rectal injuries (one patient developed recto-urethral fistula), and 1 hemorrhage, and 1 lymphocele, postoperatively. The positive margin rate for pT2 disease was 14.3 and 11.5%, and for pT3 tumors 38.8 and 29.1%, respectively. After an additional 100 procedures operated by the same residents, mean operative times were 142 and 146minutes. There was one patient who needed a transfusion. Postoperative complications requiring re-intervention were 1 hemorrhage, 2 anastomotic leakages and 4 symptomatic lymphoceles. The positive margin rate for pT2 disease was 12.8% and 6.5%, and for pT3 tumors 33.3% and 26.3% respectively.No statistical significant differences were observed when comparing with the mentors cases. ConclusionWe have showed that residents with no prior experience in open surgery of the pelvis can adhere to the modular training scheme and successfully perform the EERPE procedure with similar risk of complications compared to the tutor.

Laparoscopic radical prostatectomy – impact of training and supervision

To define the influence of training and supervision on the quality of laparoscopic radical prostatectomy we compared our perioperative parameters, as well as the postoperative functional and oncological outcomes of four generations of surgeons with significantly different training modalities. The first two generations were trained in open retropubic radical prostatectomy, but the third and fourth generation were trained mostly laparoscopically. Overall the data of more than 1000 performed cases were compared: We could not find any significant difference concerning our complication rates. Also the data of oncological (positive margins) and functional results (data of continence with a follow‐up of more than two years) were comparable within all groups. A learning curve was observed only for the operating time, but proved to be significantly shorter for the third and fourth generations. Therefore we can conclude that the quality of laparoscopic radical prostatectomy does not depend on the individual experience in open surgery but to a considerable extent on the quality of laparoscopic education (e.g. simulation trainer, supervision).

Total thoracoscopic pneumonectomy: indications and technical considerations

Although descriptions of series of thoracoscopic wedge resections and lobectomies have been published, with increasing frequency and encouraging results, only a handful of individual reports of minimally invasive pneumonectomy are available. The authors of these publications unanimously have used a limited 6to 16-cm thoracotomy to allow the introduction of traditional surgical instruments and to provide some direct visualization of the surgical field, especially the hilar structures. This has been traditionally accepted as the method of choice in video-assisted thoracic surgery (VATS). However, it is arguable, that the requirement for a minithoracotomy, particularly if rib spreading or rib resection is used, reduces the benefits of minimal trauma associated with the smaller incisions. VATS wedge resections and anatomic lobectomies are frequently performed. The indications, preoperative patient workup, postoperative care, and basic oncologic principles are essentially the same as with open thoracic surgery. We use preoperative mediastinoscopy before any lung cancer resection. We discuss here our initial experience with entirely videothoracoscopic pneumonectomy, such as has not been reported to date.

A new T-tube applier in laparoscopic surgery

In the majority of patients undergoing laparoscopic choledochotomy, it is advisable to insert a T-tube into the duct after ductal exploration, as bile sludge or fibrin deposits may obstruct the papilla and cause postoperative cholangitis. Based on our experience in open surgery, a limited transverse choledochotomy is preferred, which reduces the possibility of damaging the common bile duct blood supply. Such a technique can complicate laparoscopic T-tube positioning, however. After experimenting with the method described by Kitano et al. [Surg Endosc 7:104-105 (1993)], which was abandoned because it was difficult to carry out with the type of soft silicone rubber tubes that we normally use, two subsequent techniques were developed and are described. They were employed in 3 and 10 patients, respectively, out of 21 who underwent laparoscopic transverse choledochotomy. The most satisfying results were obtained using a system employing two sets of telescopic cannulae of different diameters. Laparoscopic T-tube introduction through a transverse choledochotomy using two telescopic cannulae was rapid and safe and allowed to precisely guide T-tube positioning inside the common duct.