Extracorporeal Knot Research Articles

Bringing the Skills Laboratory Home: An Affordable Webcam-Based Personal Trainer for Developing Laparoscopic Skills

The purpose of this work was to develop a more flexible system of laparoscopic surgery training with demonstrated effectiveness and construct validity. A personal, portable, durable laparoscopic trainer can be designed at low cost. The evaluation of expert surgeons on this device will reveal technical superiority over novices. With practice, novice surgeons can improve their performance significantly as measured by scores derived from performing skills with this training device. Prospective trial with observation and intervention components. The first aspect was observational comparison of novice and expert performance. The second was a prospective static-group comparison with pretest/posttest single-sample design. Tertiary-care academic medical center with affiliated general surgery residency. A total of 21 junior surgical residents and 5 experienced operators. Performance was assessed by the 5 tasks in the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS): pegboard transfer, pattern cutting, placement of ligating loop, extracorporeal knotting, and intracorporeal knotting. Each task was assessed for accuracy and speed. Expert surgeons scored significantly higher than novices on total score and 4 of the 5 MISTELS tasks (peg transfer, pattern cut, extracorporeal knot, and intracorporeal knot). After 4 months of home-based training, the novices improved in total score and 3 of the 5 tasks (peg transfer, pattern cut, and extracorporeal knot). A low-cost personal laparoscopic training device can be built by individual residents. With their use, residents can significantly improve performance in important surgical skills. Evaluation of the system supports its validity.

Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques

Purpose Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in children. The objective of this study was to compare intracorporeal suturing and knotting with extracorporeal knotting for repair of congenital inguinal hernia in infants and children about operative time, recurrence rate, hydrocele formation, and postoperative cosmetic results. A randomized controlled study was carried out in the Pediatric Surgery Unit of Al-Azhar University Hospitals (Cairo, Egypt) over a 3-year period. Patients and Methods One hundred fifty patients with congenital inguinal hernia were randomized into 2 equal groups (n = 75). Group A was subjected to intracorporeal purse string suture around the internal inguinal ring (IIR) using 2 needle holders. Group B was subjected to insertion of purse string suture around IIR using a Reverdin needle (RN) and extracorporeal knotting. Inclusion criteria included bilateral inguinal hernia, recurrent hernia, hernia in obese children, incarcerated hernia, and ipsilateral hernia with questionable hernia on the contralateral side. Exclusion criteria included unilateral inguinal hernia and hernia with undescended testicles. The main outcome measurements were operative time, length of hospital stay, postoperative hydrocele formation, recurrence rate, and cosmetic results. Results There were no significant differences about age, sex, and mode of presentation between both groups. All cases were completed successfully without conversion. There were significant statistical differences in the operative time, recurrence rate, and cosmetic results between the studied groups, whereas there were no significant statistical differences in the hospital stay and postoperative hydrocele formation. Conclusion Laparoscopic hernia repair by RN is an effective method of hernia repair in infants and children. It resulted in a marked reduction of operative time and excellent cosmetic results with low recurrence.

Technical Refinements in Single-Port Laparoscopic Surgery of Inguinal Hernia in Infants and Children

The techniques of minimal access surgery for pediatric inguinal hernia are numerous and they continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port endoscopic-assisted percutaneous extraperitoneal closure seems to be the ultimate attainment, and numerous techniques have mushroomed in the past decade. This article comprehensively reviews and compares the various single-port techniques. These techniques mainly vary in their approaches to the hernia defect with different devices, which are designed to pass a suture to enclose the orifice of the defect. However, most of these emerging techniques fail to entirely enclose the hernia defect and have the potential to lead to higher incidence of hernia recurrence. Accompanying preperitoneal hydrodissection and keeping identical subcutaneous path for introducing and withdrawing the suture, the suture could tautly enclose the hernia defect without upper subcutaneous tissues and a lower peritoneal gap, and a trend towards achieving a near-zero recurrence rate.

FLS Skill Retention (Learning) in First Year Surgery Residents

Fundamentals of Laparoscopic Surgery (FLS) certification is reliable and valid; the American Board of Surgery requires FLS certification. Dynamics of skill retention after FLS training effect training schedules for residents. We hypothesized that the initial elevation of performance levels after FLS training would deteriorate predictably with time. FLS performance data on 16 new surgical residents (R01s) was examined retrospectively. These R01s trained at 16 weekly sessions. Training included 4 FLS tasks, VR simulator tasks, and open surgical skills. FLS skills were practiced weekly with feedback but no instruction. Performance was tested PRE, POST, and DELAY. Outcome metrics were task completion times (TCTs). POST TCTs were below PRE TCTs in all R01s for all FLS tasks (P < 0.05). No difference was seen between the DELAY TCT and POST TCT for peg transfer (P = 0.726) and pattern cut (P = 0.114). The DELAY TCTs were longer than POST TCTs for extra- and intra corporeal knot-tying (P < 0.0001 and P = 0.029). Relative retention was 103% for peg transfer, 85% for pattern cut, 47% for extracorporeal knot tying, and 59% for intracorporeal knot tying. However, many individual's displayed DELAY TCT equal to or lower than POST TCT implying full retention. This study extends the data on FLS skill retention to an actual "production" training curriculum. This FLS training provided effective learning in R01s. Although performance levels fell across these tasks on average and for the majority of individual R01s, significant skill retention remained at 7-8 months. Early training will enable R01s to maintain or elevate skill levels with additional training sessions.

Tip/Trick 1

OBJECTIVES: To determine the effect of self-directed skill practice with weekly verbal feedback sessions for learning basic open and laparoscopic surgical skills in first year Obstetrics and Gynecology (OBGYN) residents. MATERIALS AND METHODS: First year OBGYN residents entering in July 2009 received a study guide consisting of five learning modules: instrument identification, suturing, knot tying, basic laparoscopic skills, and advanced laparoscopic skills. Each module contained 1) a learning map with prerequisite knowledge and skills, unit contents, and criterion-referenced learning objectives that trainees were expected to meet by the end of the training period, and 2) principles of technique, common errors, and prevention strategies. Each resident was given a take-home skills training box that included: suturing and knot tying boards, a portable laparoscopy training box, and videos. In addition to home training, residents attended 4 weekly practice sessions for 60 min/session. Assessments occurred at baseline and 6 weeks after starting the curriculum in knowledge of surgical instruments and skill performing open suturing, knot tying, and Fundamentals of Laparoscopic Surgery (FLS) tasks including peg transfer, cutting, intracorporeal, and extracorporeal knot tying. These tasks are mandatory skills for graduating general surgery residents. The primary outcome was resident performance using global rating scale (GRS) scores and FLS expert-derived cutoff time criteria. RESULTS: All 7 first year residents participated. Median non-supervised practice time was 125 (98–158) minutes per week. Basic instrument identification improved from 6 (18%) to 29 (85%) instruments (P < .001). Residents' performance significantly improved from baseline to posttest in 10/13 skills including: simple interrupted [GRS score = 1 (0–1) to 4 (2–4) P < .01] simple running [1 (1–2) to 3 (1–4) P < .03], and simple subcuticular suture [1 (0–2) to 3 (2–4) P < .03]; instrument handling while suturing [1 (0–2) to 3 (3–4) P < .03]; one-handed square knot at depth [0 (0–2) to 3 (0–4) P < .03]; laparoscopic peg transfer [192s (±52) to 70s (±40) P = .003]; cutting [233s (±64) to 103s (±25) P = .006]; intracorporeal suturing [300s to 166s (±70) P = .005] and extracorporeal suturing [300s to 153s (±46) P < .001]. All residents reached competence cutoff scores in suturing and instrument handling while 71% reached competence in knot tying and efficiency of movement. Two first year residents were able to successfully perform laparoscopic peg transfer and intracorporeal suturing within cutoff times while 3 were able to successfully perform laparoscopic cutting and extracorporeal suturing within cutoff times. On average, trainees reported being 60% (50–100) better than before they started the curriculum. The majority (86%) of residents reported they would recommend continuing the curriculum for learning surgical skills in their residency, while 7/7 (100%) recommended this curriculum to future incoming first year residents. CONCLUSION: Self-directed skill practice with weekly feedback sessions improves formal basic and advanced surgical skill learning in first year residents.

Oral Poster 6

OBJECTIVES: The purpose of the study was to test a home built, easily portable laparoscopic trainer with a realistic, mobile camera for resident training. We sought to compare outcomes after an instructor training session vs. an online self study instructional video. MATERIALS AND METHODS: A box trainer was built using a suitcase, spy camera with LED light source mounted in a metal tube, and a camera receiver with wireless connection to a small TV screen, for under $200. All materials including laparoscopic graspers and knot pushers fit inside the suitcase for transport. Residents were given five tasks to complete on their own including passing a pipe cleaner through hooks, placing washers on pegs, unwrapping an aluminum foil ball, tracing a maze, and extracorporeal knot tying. They were randomized to direct instruction on the use of the trainer (controls) vs. self study using a video posted on YouTube. Self reported timed results for each task were compared, stratified by level of training. They also completed a questionnaire on realistic feel, technical problems with box trainer, comfort with trainer, need for the trainer and surgical applicability of the trainer using a Likert-type scale (1 = strongly disagree, 5 = strongly agree). RESULTS: The apparatus is presented in figure 1. Eighteen residents were randomized to a 25 minute session with an instructor or to the video. There was no difference in outcomes in timed performance for each task between the two groups as presented in Table 1. There was a relationship between increasing PGY level and performance, suggesting validity of the tasks. Control and video groups reported no differences in technical problems with equipment (1.7 vs 2.7, P = 0.9),comfort with trainer (4.9 vs 4.8, P = 0.66), realistic simulation of surgical feel(4.6 vs 4.6, P = 1.0), applicability of tasks (4.9 vs 4.6, P = 0.13), and current opportunity for practice(2.3 vs 2.1, P = 0.61). CONCLUSION: A homemade, realistic laparoscopic simulator can be inexpensively built and used for resident training at home with self instruction with good results. This can favorably impact time available for practice of laparoscopic skills and demands on faculty and finances.

An Ex-Vivo Evaluation of the Application and Strength of a Novel Laparoscopic Knot Substitute Device

Intracorporeal suturing can be challenging, especially in the case of laparoscopic partial nephrectomy. During these procedures, suturing must reapproximate renal tissue to achieve hemostasis but not tear through tissue. We present a new device, the ANPA Suturelock, which can be adjusted to increase or decrease suture tension, optimizing tissue apposition. Two participants (one experienced laparoscopist, one junior resident) completed the protocol. A laparoscopic trainer was used to secure 2-0 polyglactin suture ends in rubber foam using five of each of the following: Traditional laparoscopic suture knots (one surgeon's knot and two square knots), square-to-slip knots, Weston extracorporeal knots, ANPA Suturelock, Lapra-Ty devices, Hem-O-Lock clips, and titanium clips. Tensile strength of each knot and knot substitute was measured using an Instron machine (Instron, Norwood, MA). Time to secure the two suture ends was measured for ANPA Suturelock and laparoscopic surgeon's knot. Statistical analysis was performed using the Student t test. Mean tensile strength of the three knot-tying methods was 53.0 newtons (N) while that of the four knot substitute devices was 8.3 N (P < 0.001). Each of the three individual knot-tying methods had significantly greater tensile strength than any of the knot substitutes (P < 0.001 for all). Of the knot-tying methods, the surgeon's knot was the strongest (mean tensile strength 63.2 N) and was significantly stronger than square-to-slip and Weston extracorporeal knots (39.1 N and 48.4 N, respectively, P < 0.05 for both). Of the knot substitutes, ANPA Suturelock (mean tensile strength 14.7 N) was significantly stronger than Lapra-Ty (6.1 N), Hem-O-Lock (5.4 N), and titanium clip (3.0 N) (P < 0.01 for all). When compared with a laparoscopic surgeon's knot, the time to securing the ANPA Suturelock was significantly quicker for a third year resident (106 sec vs 38 sec, P < 0.001) and an experienced laparoscopist (75 sec vs 23 sec, P = 0.02). The tensile strengths of traditional knot-tying techniques were greater than that of any knot substitute device. The ANPA Suturelock provided the greatest tensile strength of any knot substitute. The time to secure a knot using the ANPA device was also significantly quicker than tying a standard surgeon's knot.

Laparoscopic Removal of a Large Abdominal Testicular Teratoma in a Standing Horse

To describe laparoscopic removal of a large testicular teratoma in a standing horse. Clinical report. Thoroughbred horse (11 months) with a testicular teratoma. A unilateral cryptorchid testicle could not be removed by an inguinal approach under general anesthesia because of it s large size. After recovery from general anesthesia, ultrasound evaluation revealed a 24 x 19 cm fluid-filled testicular mass. The mass was removed by paralumbar fossa laparoscopy with the horse in a standing position. After fluid aspiration of the mass, the mesorchium and ductus deferens were ligated with extracorporeal knots and the mass retrieved inside a laparoscopic specimen pouch. Morphologic features were consistent with a teratoma. Laparoscopic-guided aspiration of fluid from the teratoma decreased mass size and increased ease of manipulation and retrieval. Retrieval of the teratoma in a laparoscopic specimen pouch prevented loss of abdominal insufflation, helped reduce fluid leakage, and potential seeding of neoplastic cells. Use of laparoscopy for removal of neoplastic cryptorchid testicles offers many advantages including minimal invasiveness and increased safety associated with good visibility of structures. Standing laparoscopic surgery should be considered for removal of testicular neoplasms in horses.

Laparoscopic Suturing – Tips and Tricks

Study Objective: Laparoscopic suturing is an important skill for the minimally invasive surgeon. In this video, basic suturing techniques as well as several tips and tricks are shown in a case based fashion. The techniques shown are: intracorporeal knot tying and ovarian suspension during laparoscopic cerclage placement, three vaginal cuff closure methods using bidirectional barbed sutures or the Ti-knot device, extracorporeal knot tying, cinch knot and rectosigmoid suspension during laparoscopic apical suspension cases, suturing techniques for laparoscopic myomectomy closure and utero-ovarian suspension for added exposure during surgery for advanced endometriosis.

A New Device for Performing the Bladder Urethral Anastomosis during the Laparoscopic Radical Prostatectomy

Background: A good quality urethra-vesical anastomosis is the key for lowering the incidence of the urethral strictures. In the same time this anastomosis requires the most delicate and time consuming steps of the laparoscopic procedure. We designed and manufactured a device that allows performing the anastomosis starting from the urethra with separate stitches. Material and Method: The new technique inserts the suture needle through the urethra and allows the surgeon to perform extracorporeal knotting. The urethral anastomosis device was designed by the first author and we have a patent pending for it. We evaluated the characteristics of the vesico urethral anastomosis in 3 groups of 7 patients in which we performed it by the usual laparoscopic fashion (the first group 7 patients we used separate stitches, the second group 7 patients with continuous running sutures) and the third group using our urethral suturing device. We followed the parameters: duration of the anastomosis, number of stitches, urine leak time, and cooptation of mucosa rate. Result: The time of the anastomosis is decreased from 34 to 21 minutes by using the urethral suturing device. We were able to use more stitches when we used the urethral suturing device but the urine leak time was not significantly changed. The cooptation of mucosa was performed in all the stitches where we used the urethral suturing device. Conclusion: Using the urethral suturing device the difficulty of the urethral suturing during the vesico ureteral anastomosis is decreased. In this new manner we encountered a significant decreased anastomosis time. We postulate a lower incidence of the urethral strictures considering a better cooptation of the mucosa in the anastomosis using the urethral suturing device.

Single-Port Laparoscopic Radical Prostatectomy

To present the initial experience in laparoscopic radical prostatectomy performed exclusively through an umbilical incision using a single three-channel port and specially designed flexible laparoscopic instrumentation. Since November 26, 2007, we have performed single-port laparoscopic radical prostatectomy in 4 patients diagnosed with prostate cancer. Patients with early-stage prostate cancer (T1c), no previous pelvic surgery, and a body mass index <or=35 kg/m(2) were selected for single-port laparoscopic radical prostatectomy. A multichannel port was inserted transperitoneally through a 1.8-cm umbilical incision. No additional extraumbilical instruments or ports were inserted. Urethrovesical anastomosis was performed using free-hand interrupted suturing and extracorporeal knot tying. Data were collected prospectively into our institutional review board-approved data registry. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time was 285 +/- 30 minutes, with a mean operative time for prostate excision and urethrovesical anastomosis of 3.25 hours and 1.1 hours, respectively. The mean blood loss was 288 +/- 131 mL, and no patient required a blood transfusion. The hospital stay was 2.5 +/- 0.6 days. The Foley catheter was removed 2 weeks (range 1-3) after surgery. No intraoperative complications occurred; however, 1 patient developed a rectourethral fistula that was noted 2 months after surgery. At 18 weeks of follow-up, 3 patients used 1 or 0 pads for continence daily, 2 patients had positive margins noted at the site of extracapsular extension, and all patients had an undetectable prostate-specific antigen level. Single-port laparoscopic radical prostatectomy is feasible. Additional investigation is needed to evaluate the safety and oncologic adequacy of this new approach.

Laparoscopic Reconstructive Pelvic Surgery with AirSeal™

This video demonstrates a Laparoscopic Supracervical Hysterectomy with Sacrocervicopexy using a novel trocar technology, Airseal™, which uses high velocity gas flow to create an air barrier within the trocar. This barrier obviates the need for a traditional flap valve to prevent loss of pneumoperitoneum during laparoscopic surgery. This technology may offer benefits in tissue extraction and smoke evacuation, although it seems especially useful for laparoscopic suturing using an extracorporeal knot tying technique.

Basic Principles of Laparoscopic Suturing

Objective: This video demonstrates the basic steps and principles of laparoscopic suturing. Description: Using the operating room for basic skill acquisition for laparoscopic suturing may be inefficient and expensive. We present an educational video illustrating the basic laparoscopic suturing principles in the laparoscopy lab. The video demonstrates the details of the following laparoscopic suturing tasks: 1. Introduction of a needle through a trocar 2. Picking up and loading a needle for suturing using a laparoscopic needle-holder 3.Running a continuous suture 4.Tying an intra and extra-corporeal knot.

One‐Trocar Laparoscopic Transperitoneal Closure of Inguinal Hernia in Children

Laparoscopy is an alternative procedure for pediatric inguinal hernia; however, reported techniques necessitate two or three trocars and excellent intra-abdominal skills. This study was designed to describe and evaluate the preliminary result of one-trocar laparoscopic-assisted transperitoneal closure for inguinal hernia in children. A total of 33 children with inguinal hernia (body weight range, 2270 g to 58 kg) were included in this study from March to November 2007. Under a 5-mm laparoscopic guidance, the hernia defect was enclosed by a nonabsorbable suture, which was introduced into the abdomen by an 18-gauge vascular access on one side of the hernia defect and withdrawn on the opposite side by a homemade hook-pin through a needle puncture wound. Then, extracorporeal knot tying was performed. A total of 52 procedures were performed, and the mean operating time was 46.2 +/- 16.2 (range, 18-87) minutes. No cauterization was used during the operations and there was no serious operative morbidity. The mean follow-up period was 7.6 +/- 2.5 (range, 4-12) months. No recurrence was observed during this period. This easy technique provides the benefits of laparoscopic herniorrhaphy and combines the advantages derived from the novel use of a hook-pin and vascular access simplicity, low cost, safety, minimized tissue trauma, and improved cosmetics. In addition, only one umbilical trocar wound and another needle puncture point were made. Therefore, this procedure is recommended for pediatric inguinal hernia.

Thoracoscopic Repair for Right Congenital Diaphragmatic Hernia

The aim of this study is to describe the surgical technique and initial results of thoracoscopic repair for the right congenital diaphragmatic hernia (CDH). Patients underwent surgery under conventional general anesthesia. The operation was carried out by using one optical and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-4 mm Hg. The hernia defect was repaired by using nonabsorbable interrupted sutures with extracorporeal knots. There were 16 patients, including 13 boys and 3 girls. Six patients were newborns and the other 10 patients were infants or elders. The mean operative time was 82 minutes. Conversion was required in 1 patient. There were no operative or postoperative complications. However, there was one postoperative death. There was one recurrence on postoperative day 39. Follow-up ranged from 2 to 77 months. A normal chest X-ray was shown in all patients. Thoracoscopic repair is feasible and safe for children with a right CDH, including selected newborns.

The Efficacy of Viewing an Educational Video as a Method for the Acquisition of Basic Laparoscopic Suturing Skills

Study Objective To estimate the efficacy of viewing an educational video in the acquisition of laparoscopic suturing skills. Design A prospective observational study (Canadian Task Force classification II-2). Setting Tertiary care academic medical institution. Subjects Twelve candidates interviewing for the female pelvic medicine and reconstructive surgery fellowship position at our institution. Interventions Candidates were evaluated in the laparoscopy laboratory before and after watching a 6-minute educational video on the basic principles of laparoscopic suturing. Each candidate evaluation included the following tasks: (1) introduction of a needle through a trocar (timed in seconds); (2) load and position a needle for suturing with a laparoscopic needle holder (evaluated by number of movements); (3) running continuous suture with 2 passes (timed in seconds); (4) intracorporeal knot tying with 2 throws (timed in seconds); and (5) extracorporeal knot tying with 2 knots (timed in seconds). Measurements and Main Results Wilcoxon signed rank test was used for the statistical comparison of the candidates’ performance before and after viewing the video. After viewing the teaching video, the total median time to perform all timed tasks improved by 20% (115.5 seconds, p = .009). Significant improvement occurred in the median time of introducing the needle through a trocar, continuous suturing, and extracorporeal knot tying (p = .02, p = .01, and p = .003, respectively). Conclusion The use of an educational video appears to be an effective method for the acquisition of basic laparoscopic suturing skills.

Goal-directed laparoscopic training leads to better laparoscopic skill acquisition

Laparoscopic skills training outside the operating room is becoming the standard for educating surgical residents. Because of the restrictions on the work week, it is imperative for this training to be efficient. We hypothesized that goal-directed laparoscopic training (GDLT) would result in better skill acquisition than laparoscopic training without goals (LT). Second-year general surgery residents participated in this study. Metrics were scores that incorporated time and errors. One group of residents (LT) went through a 10- week laparoscopic training course without goals; one group of residents (GDLT) was given goals to achieve during their course. Each group practiced for the same amount of time. The tasks were peg exercise, run the rope, pattern cutting, clip/cut vessel, extracorporeal knot tying, intracorporeal knot tying, and suturing device. Statistical analysis was performed via 2-tailed Mann-Whitney tests. There were 8 residents in the LT group and 7 residents in the GDLT. The GDLT group had statistically significant higher scores on 7 of the 8 tasks compared the LT group (P < .02 to P < .0001). The GDLT group performed better in the final task, suturing device, than the LT group, but this did not reach statistical significance (451 vs 414; P = .14). GDLT should be used by surgeons instead of LT. Future studies need to examine whether GDLT translates into a better operative technique and outcomes.

Minimal access surgery of pediatric inguinal hernias: a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons' experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.

A Prospective Evaluation of a Simulator-Based Laparoscopic Training Program for Gynecology Residents

To determine prospectively if simulator-based laparoscopic training could improve laparoscopic skills of gynecology residents. Twenty-six gynecology residents were enrolled in a laparoscopy training curriculum involving didactics, self-paced learning modules, and graded simulator-based laparoscopic training modules. Six simulator tasks were developed to introduce incremental levels of difficulty. Residents were tested on bead/peg manipulation, passing of a specially designed "key," cutting of lines and circles on a two-layer latex glove, and laparoscopic suturing followed by both intra- and extracorporeal knot tying. Times for each task and penalties for errors were assessed at baseline and after 3 months of training. Twenty-six residents completed initial baseline and 3-month evaluations. Average summary time (including 30-seconds penalties for each error) at baseline was 64 minutes and 36 minutes at 3-month evaluation (p < 0.001). For PGY1 baseline summary times averaged 83 minutes compared with 50 minutes at 3 months (p = 0.006). For PGY4 baseline summary times averaged 49 minutes compared with 28 minutes at 3 months (p = 0.05). All individual tasks demonstrated substantial improvement (p < 0.001) from baseline to 3-month evaluation. Baseline summary scores demonstrated correlation between PGY training year and overall score (p < 0.001) consistent with earlier ability and training. Three-month scores demonstrated equalization of skill level across PGY2 through PGY4. A dedicated simulator-based laparoscopic training curriculum has the ability to improve basic laparoscopic skills in a gynecologic residency, as measured by timed and scored simulator tasks. Construct validity was demonstrated by measuring substantial improvement in performance with increasing residency training, and with practice.

29: Laparoscopic Repair of Vesicovaginal Fistulae

To report three cases of laparoscopic repair of vesicovaginal fistula following laparotomic hysterectomy. Three case reports. Obstetric and Gynecology Department of the University Hospital of Verona. Three patients, age 44, 45, 50 who complained about urinary incontinence because of vesicovaginal fistulae following laparotomic hysterectomy. The diagnosis was made by cystoscopy. The first case was a supratrigonal vesico-vaginal fistula of 2-3 mm; the second case a posterior-superior 5 mm fistula located to the trigone and the last case a supratrigonal fistula of 3 mm. Initially they had cystoscopy. A n° 8 pediatric Foley catheter was used to cannulate the fistula from the vagina into the bladder to help its identification and excision. A laparoscopic procedure was conducted. A vaginal probe was used for manipulating the vaginal vault. The peritoneum covered the vaginal cuff was dissected. The vesicovaginal space was developed laparoscopically and the bladder base was freed from the vaginal wall. The fistula was identified and excised. Extramucosal interrupted sutures 1-0 Vicryl were placed both in the bladder and into the anterior vaginal wall using extracorporeal knotting. Bladder integrity with contrast was done, an intraperitoneal drain was inserted and a Foley catheter was left in place in the bladder for 7 days. No complications were recorded. All the patients were discharged 3 days after surgery and at 4 weeks follow-up they did not complain about leakage. Vaginal examination confirmed complete repair. The minimally invasive approach of laparoscopy can represent an attractive option for patients with vesicovaginal fistula following surgery with advantages such as magnification during the procedure, shorter hospital stay and quicker recovery.