Laparoscopic Intestinal Anastomosis Research Articles

Sleep deprivation among surgical residents: Does it affect performance while practising a laparoscopic intestinal anastomosis?

IntroductionTo assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. MethodsA prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. Results402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters. ConclusionsFatigue increases the risk of leakage and the time to do the exercise.

ЛАПАРОСКОПИЧЕСКИЙ МЕЖКИШЕЧНЫЙ АНАСТОМОЗ SANTULLI У МЛАДЕНЦА С МУКОВИСЦИДОЗОМ

The aim of the study was to evaluate the technical feasibility of performing a Santulli-type side-toend inter-intestinal anastomosis in infants with cystic fibrosis (CF) using laparoscopy. A clinical case of a 3-month-old child with CF who was operated on in the neonatal period for meconium ileus is presented. The baby's gestational age was 32 weeks. The primary operation consisted of the formation of a terminal enterostomy. In the postoperative period, a malabsorption syndrome was noted, accompanied by a lack of growth. As a temporary measure to restore nutritional status, a Santulli-style side-to-end laparoscopic intestinal anastomosis was performed. The observed child was found to have the F508del mutation in both alleles of the CFTR gene. The patient's weight at the time of the Santulli anastomosis construction was 2900 g, the age – 3 months. During the operation, there were no difficulties associated with the mobilization of the separated segments of the ileum. The duration of the surgical intervention was 70 min. Enteral nutrition was started on the 3rd day after the operation. The recovery period for intestinal transit through the rectum was 15 days. The postoperative period was uneventful. The duration of hospitalization was 18 days. No electrolyte imbalance or excessive fluid loss or underweight associated with enterostomy was observed. Over the next 6 months, the normalization of age-related weight and height parameters was achieved, after which the continuity of the digestive tract was restored by closing the terminal enterostomy. Currently, the patient has minimal respiratory symptoms and is receiving adequate CF therapy with pancreatic enzyme replacement therapy included with each meal. The initial experience of performing laparoscopic Santulli inter-intestinal anastomosis in an infant with CF presented in the study showed the possibility and reproducibility of this technique, expanding the boundaries of laparoscopy in pediatric practice. The decision to close the enterostomy in these patients should be deferred until a full diet is introduced and should be made in conjunction with a pediatrician specializing in the treatment of CF.

A prospective study of 50 cases of laparoscopic intestinal anastomosis by Endo GIA universal loading stapler (green/blue) versus Endo GIA articulating reload with tri staple technology (purple)

Background: Intestinal anastomosis is a commonly performed procedure in surgery. Various evolvements have occurred in the field of intestinal anastomosis and recent advancement is the use of stapler in laparoscopic surgeries as a device for Gastrointestinal (GI) anastomosis. Few previous studies evaluating the clinical safety of the 2 laparoscopic linear stapling devices are available.Methods: A prospective comparative study of 50 cases which met the inclusion and exclusion criteria were included in this hospital-based study. They were randomly allocated to two groups, Group A which underwent laparoscopic intestinal anastomosis by Endo GIA tri-staple (purple) stapler and Group B which underwent Endo GIA universal loading unit (blue/green) stapler. Primary outcome was assessed in terms of intra-operative staple line bleeding, operative time and post-operative anastomotic leak.Results: Patients with laparoscopic intestinal anastomosis by Endo GIA tri-staple stapler (purple) have required less operation time as compared to Endo GIA universal loading unit. In Endo GIA universal loading unit (blue/green) 04% patients developed anastomotic leak and 40% patients had intra-operative staple line bleed while with Endo GIA tri-staple no postoperative anastomotic leak was found and 02% patients developed intra-operative staple line bleeding.Conclusions: The result of our study has shown that the Endo GIA reload tri- staple (purple) is superior in terms of having no anastomosis leak, negligent staple line bleeding and less operation time as compared with Endo GIA universal loading unit (blue/green). Thus, laparoscopic intestinal anastomosis by Endo GIA reload tri-staple stapler (purple) technology is more effective and overall more efficient.

Development and Validation of a Tool for the Evaluation of Laparoscopic Intestinal Anastomosis in Simulation

IntroductionLaparoscopic side-to-side intestinal anastomosis is a common in clinic practice and training simulation. The aim of this study is to design and validate a reliable and reproducible tool for its evaluation. MethodsA modified Delphi method was used to design a tool with elements that determine quality, including 5 items: separation between stiches, eversion, tension, leak and iatrogenesis. The study included 21 participants (10 first-year residents and 11 experts) who performed a 5cm laparoscopic intestinal side-to-side anastomosis with porcine viscera. The evaluations were blinded and done independently by 2 evaluators. ResultsThe means obtained by novice and expert participants were, respectively: separation between stiches 3.2 vs 5.7 (P<.001), eversion 3.3 vs 5.9 (P=.004), tension 2.9 vs 5.9 (P=.001), leak tightness 3.2 vs 5.7 (P=.005), iatrogenesis 6.9 vs 7 (P=.47). The iatrogenesis parameter was not discriminatory, so it was removed from the tool. The total results were 12.5 for novices and 23.2 for experts (P=.001).The correlation between observers presented an intraclass correlation coefficient of 0.99 for the separation between stiches, 0.94 for eversion, 0.98 for tension and 0.99 for leak.The correlation between the score and the leak without pressure presented a Rosenthal's R of −0.71 (P<.001); with pressure R=−0.55 (P=.01). ConclusionsThe designed tool is valid to discriminate between novice and expert participants, presents very high concordance between observers and correlates with the risk of leak.

LAPAROSCOPIC ANASTOMOSIS IN THE ATRESIA OF SMALL BOWEL

Introduction. A complete laparoscopic intestinal anastomosis remains a challenge for pediatric surgeons. The aim of the study is to demonstrate its effectiveness in patients with small bowel atresia. Material and methods. This article describes laparoscopic surgery in a patient with small bowel atresia of type I. During laparoscopy, stitches were placed on the blind end of the atresia segment of the intestine to stabilize the movable intestinal segment; the stitches were passed transdermally to the outside. The design of the laparoscopic anastomosis did not differ from that of the open technique proposed by Jannie Louw. At the final stage of the trial, the researchers assessed immediate and long-term results after this new surgical intervention. Results. Laparoscopic intervention for small bowel atresia of type I was performed on the second day of life. The surgery lasted for 75 minutes. No complications were registered during it. The enteral nutrition was started after the decrease in the rate of losses in the gastric tube lower than 10 ml / kg / day. It was on day 3 after the surgery. A gradual increase in the volume of feeding promoted patient’s transfer to the full enteral nutrition on day 7 after the surgery. Next day, the baby was discharged from the hospital. Early follow-up revealed no any signs of anastomosis failure. One-year follow-up revealed no signs of impaired intestinal transit too. Conclusion. It seems that the care of small bowel atresia has taken a significant step forward. Anastomoses constructed laparoscopically in such patients are not only a possible option, they have demonstrated their effectiveness and safety as well.

Objective assessment of robotic suturing skills with a new computerized system: A step forward in the training of robotic surgeons.

The purpose of this study was to assess robot-assisted suturing skills on a laparoscopic intestinal anastomosis model by using a novel computerized objective assessment system. This study compared the suturing skills of 13 surgically naïve participants on an artificial intestinal anastomosis model that mimics real tissue. Each examinee sutured using da Vinci robot assistance under 2-D and 3-D visualization and with conventional laparoscopy (CL). Pressure-measuring and image-processing devices were employed to quantitatively evaluate suturing skills. Five unique criteria were used to evaluate the skills of participants. Suturing under 3-D visualization (P < 0.01) and with CL (P < 0.05) were significantly faster than under 2-D visualization. Sutures placed under 3-D (P < 0.05) and 2-D (P < 0.01) visualization had significantly better suture tension than those placed with CL, which did not meet acceptable values for suture tension. Sutures placed with CL had significantly better air pressure leakage than those placed under 2-D visualization (P < 0.05), which did not meet acceptable values for air pressure leakage and wound opening area. One participants failed to achieve full-thickness sutures with 2-D, two participants with CL, and one participant with 3-D. Using 3-D vision is necessary for complex maneuvering during robot-assisted minimally invasive surgery. Our quantitative assessment system is useful for evaluating the skill acquisition of surgeon-trainees undergoing robotic surgery training.

Teaching Methodology for the Training of a Laparoscopic Technique: Intestinal Anastomosis

Traditionally surgeons learned surgical techniques by training them directly in the patient by imitating the actions of the surgeon with more experience. Today this methodology is difficult to apply, since there are multiple factors that hinder its use. The limited time of training systems, scarcity of resources, patient safety or the need to learn new techniques of minimally invasive surgery, make the training of surgeons require a different learning methodology. This study has designed a new methodology for the learning of surgical techniques that minimizes the impact of all the previous factors on the training of surgeons. Its effectiveness in the teaching of laparoscopic manual intestinal anastomosis is analyzed. It has been asked a group of 24 expert surgeons teaching in intestinal anastomoses, which are the steps that must include the teaching of the technique. The phases evaluated with the highest score were included in the methodology. Once the steps of the methodology were designed, 25 general surgeons were chosen and divided into three groups according to their level of experience (experts, trained and beginners). Each participant performed five training sessions following the new methodology. The technical quality of the anastomosis, the overall development of the operation, as well as the feedback developed between the participants and the instructor was analyzed. After analyzing the results it was observed that structured feedback between the instructor and the participant increases the involvement of the participant in the learning process and reduces the time needed to acquire the competence. With this methodology the inexperienced participants perform the fifth anastomosis with quality parameters close to those obtained by the expert participants. In addition, this methodology allows to individualize the learning according to the needs of each participant.

Objective assessment of the suture ligature method for the laparoscopic intestinal anastomosis model using a new computerized system.

The purpose of this study was to develop a new objective assessment system for the suture ligature method employed in the laparoscopic intestinal anastomosis model. Suturing skills were evaluated objectively using this system. This study compared 17 expert surgeons, each of whom had performed >500 laparoscopic procedures, with 36 novice surgeons, each of whom had performed <15 laparoscopic procedures. Each examinee performed a specific skill assessment task using an artificial model that mimics living tissue, which is linked with the Suture Simulator Instruction Evaluation Unit. The model used internal air pressure measurements and image processing to evaluate suturing skills. Five criteria were used to evaluate the skills of participants. The volumes of air pressure leak in the expert and novice groups were 21.13 ± 6.68 and 8.51 ± 8.60 kPa, respectively. The numbers of full-thickness sutures in the expert and novice groups were 2.94 ± 0.24 pairs and 2.47 ± 0.77 pairs, respectively. Suture tensions in the expert and novice groups were 60.99 ± 11.81 and 80.90 ± 16.63 %, respectively. The areas of wound-opening in the expert and novice groups were 1.76 ± 2.17 and 11.06 ± 15.37 mm(2), respectively. The performance times in the expert and novice groups were 349 ± 120 and 750 ± 269 s, respectively. Significant differences between the expert and novice groups for each criterion were observed. The acceptable range of values for each criterion except for the number of full-thickness sutures was statistically defined by the performance of the expert group. Our system is useful for the quantitative assessment of suturing skill in laparoscopic surgery. We believe that this system is a useful tool for training and assessment of laparoscopic surgeons.

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture. Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses. Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n=177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n=15), colocolostomy (n=1), esophagojejunostomy (n=5), and jejunojejunostomy (n=22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6months of follow-up evaluation. The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.

Causes of anastomotic leakage after colorectal cancer laparoscopic-assisted surgery

To explore the causes of postoperative anastomotic leakage of colorectal cancer. A total of 1462 cases with colorectal cancer undergoing laparoscopic operation and intestinal anastomosis at our department over the last decade were analyzed retrospectively. Data analysis was performed with SPSS 13.0. The risk factors were analyzed by binary Logistic regression while the annual incidence of anastomotic leakage by trend χ(2) test. Thirty anastomotic leakage occurred in 1462 cases with an incidence rate of 2.1%. There were significant correlations of anastomotic leakage with body built, tumor location, tumor size, operation time (χ(2) = 6.117, 50.167, 36.693, 4.481, P = 0.013, 0.000, 0.000, 0.034). However, there was no correction with gender, age or histological type (P = 0.871, 0.775, 1.000). Then the significance check of binary Logistic regression equation was performed. Tumor location was an independent risk factor of postoperative anastomotic leakage for colorectal cancer. The relative risk was 2.056. The annual incidence of anastomotic leakage was statistically insignificant (χ(2) = 1.827, P = 0.176). And the difference was. The occurrence of anastomotic leakage after colorectal cancer surgery is significantly correlated with body built, tumor location, tumor size and operation time. And tumor location below peritoneal reversal is an independent risk factor of anastomotic leakage.

Comparison of laparoscopic and conventional surgery of intestinal anastomosis in dogs

The aim of this study was to evaluate operative laparoscopy in comparison with conventional laparotomy for intestinal resection and anastomosis in dogs. Eighteen adult dogs were equally and randomly divided into 3 groups: Group I: Intestinal anastomosis was performed extracorporeally, by laparoscopic-assisted surgery, in which a 5cm loop of small bowel was exteriorized through a mini-laparotomy opening (an enlarged trocar incision 1.5-2 cm in length), then surgically resected and anastomosed by simple interrupted suture 3-0 polygalactine. Group II: Underwent laparoscopic intracorporeal intestinal resection and anastomosis, in which the loop of the small bowel was suspended into the ventral abdominal wall, then it was resected and anastomsed with simple continuous suture by polygalactine 3-0. Group III: Small bowel resection and anastomosis was conducted by conventional laparotomy technique with simple interrupted pattern by polygalactine 3-0 suture. The result showed that laparoscopic intestinal resection and anastomosis by either intra- or extracorporeal techniques can be applied in dogs safely and have less morbidity rate. Intra abdominal adhesion of the omentum and even the bowel to the abdominal wall occurred in group III but not in groups I and II. The post operative hospitalization time was earlier in group I and II, as indicated by the earlier return of intestinal motility and appetite, in comparison to group III where it was delayed.