Laparoscopic Intracorporeal Suturing Research Articles

Safety and Efficacy of Barbed Sutures Compared to Non-barbed Sutures in Bariatric Surgery: An Updated Systematic Review and Meta-analysis.

Mastering intracorporeal suturing is challenging in the evolution from conventional to laparoscopic bariatric surgery. Among various techniques competing for superiority in overcoming this hurdle, we focus on exploring the potential of barbed sutures through a meta-analysis that compares outcomes to those of conventional non-barbed sutures in bariatric surgery. We conducted a comprehensive search on PubMed, Scopus, and Embase to identify studies comparing barbed sutures with non-barbed sutures in bariatric surgeries, focusing on outcomes such as operative time, suturing time, postoperative complications, and hospital stay. The statistical analysis was carried out using RStudio version 4.3.2. Heterogeneity was assessed using the Cochrane Q test and I2 statistics. Incorporating data from 11 studies involving a total of 27,442 patients, including 3,516 in the barbed suture group across various bariatric surgeries, our analysis demonstrates a significant reduction in suturing time (mean difference -4.87; 95% CI -8.43 to -1.30; p < 0.01; I2 = 99%) associated with the use of barbed sutures. Specifically, in Roux-en-Y gastric bypass, we observed a significant decrease in operative time (mean difference -12.11; 95% CI -19.27 to -4.95; p < 0.01; I2 = 93%). Subgroup analyses and leave-one-out analyses consistently supported these findings. Furthermore, we found that the mean body mass index did not significantly predict the mean difference in operative time outcome. No significant differences emerged in hospital stay or postoperative complications, including leak, bleeding, stenosis, and bowel obstruction (p > 0.05). Our study findings address barbed sutures as a potential alternative for laparoscopic intracorporeal suturing in bariatric surgery.

How to Evaluate the Effectiveness of Simulation Training in Surgery?

Simulation training in surgical procedures is an important part of the training of surgeons. The goal of simulation training is to develop the ability of physicians to perform surgical procedures in real practice. The assessment of simulation training programs is needed to analyze to improve outcomes; requirements for assessment of simulation training include an assessment of the application of surgical procedures in practice, in the general population of students. A method of assessment of surgical procedures has been developed by means of a structured interview of listeners with an assessment of practical results. The method revealed the high efficiency of the laparoscopic intracorporeal suture training program.

Method for Evaluating the Effectiveness of Simulation Training&#x0D; for Laparoscopic Intracorporeal Suturing

Laparoscopic intracorporeal suturing (LIS) is one of the key skills in laparoscopic surgery. LIS training is conducted in simulation centers and is aimed at transferring the knowledge into practice. The simulation training (ST) is focused on the development of skills that allow surgeons to perform LIS operations. However, this goal is not completely achieved: only 44,0 to 72,2 % of surgeons implement LIS skills in their practice. &#x0D; There is a need to evaluate the effectiveness of such training programs and analyze factors that may influence the results. This evaluation is required to increase the effectiveness of LIS trainings and implement the acquired skills into practice by training surgeons. &#x0D; According to commonly accepted approach to evaluation of training programs suggested by D. Kirkpatrick., the method of effectiveness evaluation allows to estimate the practical results achieved by all trainees. Unfortunately, there are no commonly accepted methods aimed at evaluating the effectiveness of LIS training programs. The existing methods estimate the results of effectiveness evaluation in simulation (Dry lab) or practically, but in small groups. Effectiveness evaluation of LIS trainings implementation in surgical practice among all trainees is related to significant financial costs and complexity.&#x0D; A new effectiveness evaluation method of LIS simulation training programs (the Method) has been suggested. It is aimed at evaluating the total amount of results and other ST effects, as well as analyzing individual factors that can influence training results. The Method includes a survey among ST participants. It has been applied to effectiveness evaluation of LIS simulation training program at Educational and Accreditation Center of the Botkin City Clinical Hospital. The survey showed that 88.9% of surgeons attending the LIS training program implemented their knowledge into practice.&#x0D; The suggested Method allows to evaluate the effectiveness of LIS simulation training and its implementation into practice among all trainees, analyze factors that can influence the training results and use the obtained results for further improvement of the training program and its methods. &#x0D; The Method may be recommended for implementation at medical simulation training centers.

Comparing Simulator Metrics and Rater Assessment of Laparoscopic Suturing Skills

Laparoscopic intracorporeal suturing is important to master and competence should be ensured using an optimal method in a simulated environment before proceeding to real operations. The objectives of this study were to gather validity evidence for two tools for assessing laparoscopic intracorporeal knot tying and compare the rater-based assessment of laparoscopic intracorporeal suturing with the assessment based on simulator metrics. Twenty-eight novices and 19 experienced surgeons performed four laparoscopic sutures on a Simball Box simulator twice. Two surgeons used the Intracorporeal Suturing Assessment Tool (ISAT) for blinded video rating. Composite Simulator Score (CSS) had higher test-retest reliability than the ISAT. The correlation between the number performed procedures including suturing and ISAT score was 0.51, p<0.001, and 0.59 p<0.001 for CSS. We found an inter-rater reliability (0.72, p<0.001 for test 1 and 0.53 p<0.001 for test 2). The pass/fail rates for ISAT and CSS were similar. CSS and ISAT provide similar results for assessing laparoscopic suturing but assess different aspects of performance. Using simulator metrics and raters' assessments in combination should be considered for a more comprehensive evaluation of laparoscopic knot-tying competency.

Pilot Evaluation of a Novel, Low-Cost, Simulation Model for Training and Assessment of Laparoscopic Intracorporeal Continuous Suturing.

Background: Laparoscopic intracorporeal continuous suturing is being employed in a growing number of minimally invasive procedures. However, there is a lack of adequate bench models for gaining proficiency in this complex task. The purpose of this study was to assess a novel simulation model for running suture. Methods: Participants were grouped as novice (LSN) or expert (LSE) at laparoscopic suturing based on prior experience and training level. A novel low-cost bench model was developed to simulate laparoscopic intracorporeal continuous closure of a defect. The primary outcome measured was time taken to complete the task. Videos were scored by independent raters for Global Operative Assessment of Laparoscopic Skills (GOALS). Results: Sixteen subjects (7 LSE and 9 LSN) participated in this study. LSE completed the task significantly faster than LSN (430 ± 107 vs 637 ± 164seconds, P ≤ .05). LSN scored higher on accuracy penalties than LSE (Median 30 vs 0, P ≤ .05). Mean GOALS score was significantly different between the 2 groups (LSE 20.64 ± 2.64 vs LSN 14.28 ± 1.94, P < .001) with good inter-rater reliability (ICC ≥ .823). An aggregate score using the formula: Performance Score = 1200-time(sec)-(accuracy penalties x 10) was significantly different between groups with a mean score of 741 ± 141 for LSE vs 285 ± 167 for LSN (P < .001). Conclusion A novel bench model for laparoscopic continuous suturing was able to significantly discriminate between laparoscopic experts and novices. This low-cost model may be useful for both training and assessment of laparoscopic continuous suturing proficiency.

Laparoscopic approach for a cesarean scar pregnancy

To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results. Video article with the description of a surgical minimally-invasive technique. Academic medical center. A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed. Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread. Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications. An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound. Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain.

Surgical Simulation Training for Medical Students: Strategies and Implications in Botswana.

The role of simulation in teaching technical skills to medical students is not yet well defined. Strategies for its use may be especially relevant where teachers, time, and resources are limited, especially in low-middle-income countries. Sixty-seven third-year and 67 fifth-year medical students at the University of Botswana were taught surgical skills by a trained peer medical student, a medical officer with no specialty training or a staff surgeon. Pre- and post-intervention performance of two basic tasks (simple interrupted suture (SIS) and laparoscopic peg transfer (LPT)) and one complex task (laparoscopic intracorporeal suture (LIS)) were assessed. Subjective measures of self-perceived performance, preparedness for internship, and interest in surgery were also measured. The simulation program decreased the time to complete the two basic tasks and improved the objective score for the complex task. Performance of the basic skills improved regardless of the seniority of the instructor while performance of the advanced skill improved more when taught by a staff surgeon. All students had similar improvements in their self-reported confidence to perform the skills, preparedness to assist in an operation and preparedness for internship, regardless of the seniority of their instructor. Students taught by a staff surgeon felt better prepared to assist in laparoscopic procedures. Simulation-based teaching of defined surgical skills can be effectively conducted by peers and near-peers. The implications are widespread and may be most relevant where time and resources are limited, and where experienced teachers are scarce.

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.

Robotic-like suturing with FlexDex Surgical System® for difficult laparoscopic suture

The field of laparoscopic surgery has experienced an exponential growth in recent years. Despite great progress in this field, standard laparoscopic tools have not been optimally developed and still have some deficiencies when it comes to mobility and ergonomics.Robotic surgery has attempted to solve these problems by improving the articulation of surgical instruments. However, it presents a series of disadvantages, among which are its high cost, low availability and the need for specific training, which conditions its profitability and hinders widespread use.We present the results of a prospective clinical series of 20 cases in which the safety, efficacy and ergonomics of FlexDex® have been tested for performing laparoscopic intracorporeal sutures. The result is a safe and functional tool that offers both control and precision in its handling, while improving the ergonomics of the surgeon. This device represents an alternative that combines the precision and range of movements of robotic surgery with the greater availability of conventional laparoscopy.

Comparison of laparoscopic percutaneous extraperitoneal closure and laparoscopic intracorporeal suture in pediatric hernia repair

BackgroundLaparoscopic inguinal repair use is rapidly growing because it is a minimally invasive surgery (MIS) technique. However, there is insufficient evidence to support the use of one MIS over others. We compared laparoscopic intracorporeal suture (LIS) and laparoscopic percutaneous extraperitoneal closure (LPEC) to determine which technique is superior. MethodsBetween February 2017 and December 2019, 260 children who underwent LPEC and 214 children who underwent LIS were enrolled. Operative time, recovery score, and patient cosmetic satisfaction were compared. A total of 108 propensity score-matched pairs were analyzed using paired t-test for continuous measurements and McNemar test for categorical variables. ResultsThe mean surgery time was lower in the LPEC group for both unilateral (15.76 ± 5.35 vs. 19 ± 5.71 min; p = 0.04) and bilateral (21.56 ± 5.7 vs. 26.38 ± 6.94 min; p = 0.01) surgeries. The LPEC group required shorter time for complete recovery (p = 0.017). The mean rating for scar visibility was higher in the LIS group (p = 0.02); however, both groups had high levels of cosmetic satisfaction (p = 0.125). ConclusionLPEC for hernia repair is safe and efficient in children and reduced operative time, hastened recovery, and provided excellent cosmetic results.

Una experiencia de integración de la Formación Sanitaria Especializada con la Universitaria de Posgrado: Entrenamiento por etapas en cirugía laparoscópica.

Antecedentes: Diseño de un modelo de simulación para formación en cirugía laparoscópica. Métodos: Dentro del Máster Anatomía Aplicada a la Clínica se implementaron tres etapas de formación progresiva en médicos residentes. La etapa 1 se realizó en simulador con material no biológico: manejo de objetos, disección con pinza y tijera, y sutura laparoscópica. La etapa 2 utilizó material biológico (tubo digestivo en fresco) en simulador, para la práctica de sección intestinal y anastomosis intracorpórea. En la etapa 3 se realizaron técnicas laparoscópicas en cadáver en fresco (apendicectomía, colecistectomía, apertura de la transcavidad epiploica, hemicolectomías derecha e izquierda). Se añadió una encuesta de satisfacción a los participantes de la actividad. Resultados: El programa se impartió a 6 residentes de Cirugía General. Todos completaron los ejercicios de las etapas 1 y 2. En la etapa 3 se pudo realizar el neumoperitoneo sin dificultad y los tejidos presentaron una textura adecuada. Los residentes de primer año completaron la apendicectomía y la colecistectomía, pero procedimientos más complejos requirieron residentes con más experiencia. Los participantes encuestados reflejaron que el programa es adecuado y útil para el entrenamiento en laparoscopia. Conclusiones: El modelo propuesto es reproducible y adecuado en adquisición de competencias básicas en cirugía laparoscópica. Background: Design of a simulation model training in laparoscopic surgery for surgical residents. Methods: Three stages of progressive training were programmed within a Postgraduate Degree in Clinical Anatomy. Stage 1 was performed in a box-trainer with synthetic materials: managing small objects, dissection with clamp and scissors, and laparoscopic intracorporeal suture. Stage 2 used biological material (fresh digestive tract from a human corpse) in box-trainer, practicing section and intracorporeal anastomosis. In stage 3, laparoscopy was performed on a fresh corpse (appendectomy, cholecystectomy, lesser sac opening, right and left colectomy). A satisfaction survey was carried out to the participants. Results: Some six General and Digestive Surgery residents took the program. All of them completed the stage 1 and 2 exercises. In stage 3, the pneumoperitoneum could be performed without any complications, and tissues presented an adequate texture. First-year residents completed appendectomy and cholecystectomy, but more complex procedures required more experienced residents. The participants reflected that the program is adequate and useful to gain basic skills in laparoscopy. Conclusions: The proposed model is reproducible and adequate in acquisition of basic skills in laparoscopic surgery.

Sutura laparoscópica mecanizada con FlexDex Surgical System® para ubicaciones anatómicamente difíciles

The field of laparoscopic surgery has experienced an exponential growth in recent years. Despite great progress in this field, standard laparoscopic tools have not been optimally developed and still has some deficiencies when it comes to mobility and ergonomics.Robotic surgery has attempted to solve these problems by improving the articulation of surgical instruments. However, it presents a series of disadvantages, among which are its high cost, low availability and the need of a specific training, which conditions its profitability and hinders a widespread use.We present the results of a prospective clinical series of 20 cases in which the safety, efficacy and ergonomics of FlexDex® have been tested for performing laparoscopic intracorporeal sutures. The result is a safe and functional tool that offers both control and precision in its handling, while improves the ergonomics of the surgeon. This device represents an alternative that combines the precision and range of movements of robotic surgery with the greater availability of conventional laparoscopy.

Effect of structured training in improving the ergonomic stress in laparoscopic surgery among general surgery residents.

Minimal access surgery has fast become the standard of care for many operative procedures, but is associated with lot of ergonomic stress to the surgeons performing these procedures, which may result in reduction in surgeon's performance and work capacity. In this study, we evaluated the impact of structured training program in improving the ergonomic stress in trainee laparoscopic surgeons. Laparoscopic surgeons were divided in 2 groups: trainee surgeons (ten) and expert surgeons (three). Baseline surface electromyography (sEMG) data were collected from bilateral deltoid, biceps brachii, forearm extensors, and pronator teres during a predefined suturing task on Tuebingen trainer with integrated porcine organs in both the groups. Trainee surgeons underwent 20h of laparoscopic intra-corporeal suturing training and surface electromyography data were recorded at the end of training again and compared with baseline. Experts were found to have lower muscle activation (p < 0.05) and muscle work (p < 0.05) and better bimanual dexterity than the trainee surgeons at baseline. After training, the trainee surgeons showed significant improvement (p = 0.01), but still did not reach the values of the expert surgeons (p = 0.01). Right deltoid and pronator teres muscles were found to have maximal activity while performing intra-corporeal suturing. Structured and focused training outside operation theater can significantly reduce unnecessary muscle activation of trainee laparoscopic surgeons and better dexterity leading on to lesser ergonomic stress and thus possibly may reduce the risk of development of future musculo-skeletal disorders.

The effect of verbal feedback, video feedback, and self-assessment on laparoscopic intracorporeal suturing skills in novices: a randomized trial.

Laparoscopic skill acquisition involves a steep learning curve and laparoscopic suturing is an exceptionally challenging task. By improving the way feedback is given, trainees can learn these skills more effectively. This study aims to establish the most effective form of structured feedback on laparoscopic suturing skill acquisition in novices, by comparing the effects of expert verbal feedback, video review with expert feedback (video feedback), and video review with self-assessment. A prospective randomized blinded trial comparing verbal feedback, video feedback, and self-assessment. Novices in laparoscopic surgery were tasked with performing laparoscopic suturing with intracorporeal knot tying. Time was given for practice, and pre- and post-feedback assessments were undertaken. Suturing performance was measured using a task-specific checklist and global ratings. A post-study questionnaire was used to measure participant-perceived confidence, knowledge, and experience levels. Fifty-one participants were randomized and allocated equally into the three groups. Performance in all three groups improved significantly from baseline. Video feedback had the largest improvement margin with checklist and global score improvements of 17.1% (± 9.9%) and 14.7% (± 9.3%), respectively. Performance improvements between groups were statistically significant in the global components (p = 0.004) but not the checklist components (p = 0.186). Global score improvement was significantly better in the video feedback group but was statistically insignificant between the self-assessment and verbal feedback groups. Questionnaire responses demonstrated positive results in confidence, knowledge, and experience levels, across all three study groups, with no differences between the groups (p > 0.05). Structured video feedback facilitates reflection and self-directed learning, which improves the ability to develop proficiency in surgical skills. Combining both self-assessment and video feedback may be beneficial over verbal feedback alone due to the advantages of video review. These techniques should therefore be considered for implementation into surgical education curricula.

Laparoscopic Pediatric Inguinal Hernia Repair; Intracorporeal Purse-String Suture Using Needlescopic 2-mm Instruments.

PurposeTwo-millimeter needlescopic instruments induce minimal damage to the abdominal wall and have excellent cosmetic benefits. We aimed to evaluate the feasibility of a laparoscopic intracorporeal suture using 2-mm instruments for pediatric inguinal hernia.MethodsWe retrospectively reviewed 131 patients who underwent laparoscopic repair between March 2011 and February 2017. Three trocars were used: a 5-mm umbilical trocar for a needle holder and two 2-mm trocars for a camera and a grasper. The internal ring was closed with an intracorporeal purse-string suture. A telephone interview was conducted to confirm recurrence.ResultsIn the 131 patients, 169 procedures were successfully performed. The ages ranged from 2 months to 14 years (mean, 52.5 months), and the mean body weight was 18.0 kg (range, 6.7~49 kg). The mean operating time was 42 minutes for the unilateral cases and 46 minutes for the bilateral inguinal hernia repairs. All the cases were completed laparoscopically without intraoperative complications. Herniotomy was not performed in all the patients except nine. A contralateral patent processus vaginalis was present in 27.3% (35/128) of the patients. During the mean follow-up period of 54.6 months, 3 recurrences (2.3%) were observed. Two recurrences were treated using laparoscopy and one using open herniorrhaphy. Hydrocele occurred in one male patient. No wound complications or umbilical hernias developed. No testicular atrophy was observed.ConclusionThis study showed that laparoscopic intracorporeal internal ring suture using 2-mm instruments for pediatric inguinal hernia was technically feasible and safe, with excellent cosmetic results.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases

The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills. To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy. Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hβCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay. Median age and gestation at surgery were 31years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300mL (range 100-3500), and five women had blood loss >500mL. The median serum hβCG level was 6429IU/L (range: 1800-58690), and the median ectopic size was 4cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population. We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.

Struggling Prior to a Teaching Event Results in Superior Short-Term Skills Acquisition in Novice Learners

The act of generating an answer/solution before a learning episode has been shown to enhance performance, even if the learner produces incorrect answers/solutions. This phenomenon has been termed the pretesting effect. In essence, allowing a learner to struggle prior to instruction may be beneficial. The benefits of the pretesting effect have been demonstrated with declarative knowledge (i.e., facts). The objective of this study was to investigate whether the benefits of the pretesting effect extend to acquisition of procedural skill. Prospective, randomized, pretest-posttest experiment. Forty-two first- and second-year medical students enrolled at the University of Texas Health Science Center at San Antonio completed this study. Participants were randomly assigned to 1 of 2 instructional conditions. Participants in the teach-first (TF) condition watched a detailed instructional video of laparoscopic intracorporeal suturing and knot-tying (ICSKT) with auditory and text step-by-step instructions prior to attempting the exercise. In contrast, participants in the struggle-first (SF) condition attempted the ICSKT exercise prior to watching the instructional video. All participants completed 4 trials of ICSKT. The first trial was scored as the pretest and the final trial was the post-test. Participants in the TF group had higher pretest scores than participants in the SF group, however these differences were not significant. Despite the pretest deficit, participants in the SF group had higher post-test scores compared to the TF group (p = 0.03). Allowing learners to struggle with a procedural skill prior to receiving instruction results in superior acquisition of psychomotor skills.

The "Twitching Technique": A New Space-Irrespective Laparoscopic Ligation Technique Using a JAiMY Needle Holder.

Background: Laparoscopic intracorporeal sutures and knots require advanced techniques in children. The JAiMY® needle holder (Endocontrol Company, Grenoble, France), a flexible jaw with both clockwise and anticlockwise revolving functions, enables the placement of sutures in very small working spaces. Using this tool, a novel new ligation method, which we named "twitching technique," can be performed. Methods: To perform the "twitching technique," first grasp the long tail of the thread with the JAiMY and the forceps on the needle side. Then, rotate the tip of the needle holder halfway in either direction and bring the forceps closer to the needle holder to make a ring using the thread. Grasp the thread at the crossing point with the forceps, and then catch the short tail through the ring with the needle holder. Results (Case Presentation): A 1-year-old boy presented with vomiting because of esophageal hiatal hernia. He was being treated for single ventricle and asplenia at our hospital. Laparoscopic esophageal hiatus plication was performed. Although the working space was extremely limited, the JAiMY and the "twitching technique" enabled steady suture placement and ligation. Conclusions: The "twitching technique" is an easy, steady, and safe method for performing ligation in difficult situations and may facilitate the performance of many laparoscopic surgeries in pediatric fields.

Evaluating veterinary student skill acquisition on a laparoscopic suturing exercise after simulation training.

To determine whether veterinary students could train to a predefined proficiency level on a simulated intracorporeal laparoscopic suturing task. Single group preinterventional and postinterventional study. Ten veterinary students. Ten veterinary students completed a questionnaire about prior experiences and watched a 7-minute demonstration video prior to performing a laparoscopic intracorporeal suture task on a simulator. Participants were tested at pretraining and for a period of 8 weeks. Overall group improvement in scores and time to completion (seconds) from pretraining to final testing was analyzed by using a Wilcoxon matched-pairs signed-rank test. The same variables were compared among individuals with different background experiences (eg, video game experience) by using a Mann-Whitney U test. The average number of repetitions to reach proficiency was recorded. All participants reached the predefined proficiency level on the Fundamentals of Laparoscopic Surgery intracorporeal suture task. The average number of repetitions required to reach proficiency was 18 ± 7, and there was significant improvement in both time to completion (seconds) and scores from pretraining to final testing (P = .005). The number of repetitions required to reach proficiency, pretraining times, final times, pretraining scores, and final scores did not differ among veterinary students with different background experiences. Veterinary students naïve to laparoscopic surgery can learn the technical skills required to perform a simulated intracorporeal suture through repetitive, self-directed practice on a laparoscopic box trainer regardless of prior experiences (eg, videogame experience, craft experience, chopstick use, etc). Simulation offers an adequate platform for the standardized training of laparoscopic skills in veterinary students and likely novice laparoscopic surgeons.

Benefits of laparoscopic posterior wall suture repair in treating adolescent indirect inguinal hernias.

Adolescent inguinal hernias are treated using high ligation or posterior wall suture repair with laparoscopic mesh implantation. This study aimed to evaluate the efficacy of laparoscopic intracorporeal posterior wall suture repair without mesh implantation for treating adolescent indirect inguinal hernias. Laparoscopic herniorrhaphy was performed between September 2012 and April 2015 in 244 patients aged 11-18years who were diagnosed with indirect inguinal hernias at Damsoyu Hospital, Seoul, Korea. The patients were stratified by surgical procedure into the high-ligation (115 patients) and wall suture (129 patients) groups. Four (3.5%) of the 115 patients in the high-ligation group experienced recurrence, but those in the wall suture group did not. The difference in recurrence rates between these groups was significant (p<0.001). The wall suture procedures were longer (mean 28.2min) than the high-ligation procedures (mean 17.4min) (p<0.001). The lengths of postoperative hospital stays were similar in both groups. Few complications were observed: one patient developed hematoma and one developed seroma in the high-ligation group; two patients developed inguinal hematomas and one developed seroma in the wall suture group. Visual analog scale scores at 1week after surgery and the mean times to return to normal activities were similar in both groups. No chronic inguinodynia after the operation in either group was observed. Laparoscopic intracorporeal posterior wall suture repair without mesh implantation was effective for treating adolescent indirect inguinal hernias and resulted in fewer recurrences than those with high ligation.