Laparoscopic Suturing Research Articles

The Fundamentals of Laparoscopic Suturing (FLS) “Illusion of Validity” in Laparoscopic Vaginal Cuff Suturing. Is There Anything Better?

Study Objective The “illusion of validity” is a cognitive bias in which the ability to interpret and predict surgical performance accurately is overestimated. To address this cognitive bias, and to determine the most representative task for laparoscopic cuff suturing, we assessed participants on simulation tasks and in placement of the first suture in the vaginal cuff of a cadaver. Design Validity (Messick Framework) study comparing FLS and non-FLS tasks to cadaveric vaginal cuff suturing. Setting Simulation center cadaver lab. Patients or Participants Obstetrics and gynecology residents (n=21), fellows (n=3), gynecologic surgical subspecialists (n=4), general obstetrician/gynecologists (n=10). Interventions Tasks included a simulated vaginal cuff (ipsilateral port placement), needle passage through a metal eyelet loop (contralateral and ipsilateral), and intracorporeal knot tying (contralateral and ipsilateral). Times on these tasks were compared to the placement of the first cadaveric vaginal cuff suture time, as well as the in-person and blinded Global Operative Assessment of Laparoscopic Skills (GOALS) score (validity evidence). Statistical analyses included Spearman's test of correlation (continuous and ordinal variables) or Wilcoxon rank sum test (categorical variables). Measurements and Main Results A strong agreement between the in-person and blinded GOALS (ICC=0.80), and strong correlations of cadaver cuff time with in-person (Spearman's r:-0.84,P Conclusion Laparoscopic cadaveric vaginal cuff suturing performance was generally poor among residents and non-subspecialist gynecologists suggesting an “illusion of validity” in current surgical assessments. Since gynecology specific validity evidence has not been established for the FLS intracorporeal suturing task, we recommend prioritizing the use of a simulated-vaginal cuff suturing assessment instead of FLS.

Comparing Participant-Reported Confidence during Laparoscopic Vaginal Cuff Suturing after Training with Two Laparoscopic Simulators

Study Objective To determine if participants’ self-reported confidence level with performing a laparoscopic gynecologic surgical task was higher after training with a gynecology-specific laparoscopic trainer. Design Randomized controlled trial incorporating block randomization and a masked design. Setting Participants were trained and tested during a four-hour session in the Northwestern Center for Advanced Surgical Education simulation lab. Patients or Participants 45 surgically naive premedical and preclinical medical students were recruited from June-November 2019. Interventions Participants were randomized into two laparoscopic simulator groups – Essentials in Minimally Invasive Gynecology (EMIG) or Fundamentals of Laparoscopic Surgery (FLS) – then underwent training on relevant simulation tasks for 2.5 hours (including peg transfer and intracorporeal knot tying). Measurements and Main Results Participants completed a video-recorded pre-test and post-test on a laparoscopic vaginal cuff suturing model. Videos were masked then graded using a modified version of the Global Operative Assessment of Laparoscopic Skills (GOALS) tool by high-volume minimally invasive gynecologic surgeons. Participants were not aware of their GOALS scores. All participants completed a survey at the conclusion of the session, rating their confidence level during each laparoscopic simulation task on a 5-point Likert scale. Confidence scores were compared using two sample t-tests with unequal variances. No statistically significant differences in confidence levels were noted between EMIG and FLS participants: peg transfer (diff=0.03, p=0.88), intracorporeal knot tying (diff=0.15, p=0.55) and vaginal cuff suturing (diff=0.41, p=0.11). Conclusion Neither EMIG participants nor FLS participants had higher self-rated confidence scores for the simulator tasks or the vaginal cuff suturing task with regard to statistical significance. However, when examining the raw data, confidence scores for all three tasks were higher for EMIG participants than FLS participants. These results suggest that EMIG-randomized participants may have felt better prepared to complete a laparoscopic gynecologic surgical task; however, larger studies are needed to demonstrate this conclusively.

Single Site Laparoscopic Myomectomy

Study Objective My objective in making this video is to share how we approach laparoscopic myomectomy in a patient with large uterine leiomyoma. Design Video presentation. Setting Hospital, operating room. Patients or Participants Laparoscopic myomectomy case was presented. Interventions Myomectomy. Measurements and Main Results N/A Conclusion I present a case of laparoscopic myomectomy, demonstrating myomectomy and suturing techniques, as well as leiomyoma morcellation through the umbilicus.

Fine Motor Skills Task Experience and Laparoscopic Vaginal Cuff Suturing Performance after Training with Two Laparoscopic Simulators

Study Objective To determine if prior video gaming or fine motor skills task experience was associated with improved performance on a vaginal cuff suturing task following training with two laparoscopic simulators. Design Randomized controlled trial incorporating block randomization and a masked design. Setting Participants were trained and tested during a four-hour session in the Northwestern Center for Advanced Surgical Education simulation lab. Patients or Participants 45 surgically naive premedical and preclinical medical students were recruited from June-November 2019. Interventions Participants were randomized into two laparoscopic simulator groups – Essentials in Minimally Invasive Gynecology or Fundamentals of Laparoscopic Surgery – then underwent training on relevant simulation tasks for 2.5 hours. Measurements and Main Results Demographic information was collected for all participants, including fine motor skills task and video gaming experience. Participants completed a video-recorded pre-test and post-test on a laparoscopic vaginal cuff suturing model. Videos were masked then graded using a modified version of the Global Operative Assessment of Laparoscopic Skills (GOALS) tool by high-volume minimally invasive gynecologic surgeons. Two sample t-tests with unequal variances were employed to compare GOALS scores. Significant differences were noted in baseline pre-test composite GOALS scores for participants with prior experience playing instruments (diff=2.7, p=0.007), sewing (diff=2.3, p=0.03) and completing artistic tasks (diff=3.05, p=0.01). However, the mean difference between post- and pre-test composite GOALS scores was not different for participants with prior video gaming or fine motor skills task experience. Conclusion Participants with prior fine motor skills task experience performed better at baseline on the pre-test vaginal cuff model. However, after training, these same participants did not perform better when compared to those without prior fine motor task skill experience, regardless of simulation group. These results suggest that prior fine motor skills task experience may not predispose surgically naive learners to improved performance with certain laparoscopic simulation tasks.

Laparoscopic and Robotic Mesh-Free Suture Hysteropexy Versus Mesh Sacral Hysteropexy: A Non-Randomised Comparison

Study Objective To compare the laparoscopic and robotic mesh-free suture hysteropexy (SutureH) with mesh sling sacral hysteropexy (MeshH) for uterine prolapse. Design A retrospective clinical audit of consecutive women who underwent SutureH or MeshH by laparoscopic or robotic route by a single surgeon. Subjects were assessed at baseline, 5-weeks and 1-year. Setting N/A Patients or Participants N/A Interventions SutureH uses sutures to re-support the uterus from each uterosacral ligament. During MeshH, the uterus is suspended form the sacral promontory using a mesh sling placed around the cervix. All women had a post-operative surgical support pessary placed for 5 weeks. Measurements and Main Results The primary outcome was success defined as a composite of: POP-Q C-point above the hymen, absence of vaginal bulge symptom, and no repeat prolapse surgery or pessary placement. Secondary outcomes included subjective improvement in prolapse symptoms using PGI-I, POP-Q C-point change, change in POP-Q scores and complications. 228 women underwent laparoscopic or robotic hysteropexy between Sept 2010 and Oct 2018. The 1-year data was available for 191 women (MeshH n=120; SutureH n=71). Success was not different between MeshH and SutureH (P=0.114). For MeshH v's SutureH, C-point at or above -1cm, absence of bulge and no repeat surgery was 99.2% v's 95.8%, 90.8% v's 90.1% and 81.7% v's 84.5% respectively (NS). MeshH (mean C point -7.14 cm) provided better apical support than SutureH (mean C point -5.9) (P Conclusion Laparoscopic and robotic sutureH and meshH provide women with minimally invasive durable options for uterine preservation during pelvic organ prolapse surgery. When controlling for age, MeshH provided better anatomic support than SutureH although SutureH gives women a mesh-free option.

Ultrasound Guided Laparoscopic Radiofrequency Ablation for Very Large Multi-Fibroid Uterus

Study Objective This video describes the technique and advantages of laparoscopic radiofrequency ablation with ultrasound guidance for the treatment of very large multi-fibroid uteri. Design N/A Setting Large tertiary care hospital. Patients or Participants 45-year-old gravida 2 para 0 female with menorrhagia, dysmenorrhea, and bulk symptoms secondary to a very large multi-fibroid uterus. She desired a minimally invasive and uterine conserving method to treat her symptoms. Interventions We performed laparoscopic radiofrequency ablation under ultrasound guidance for the patients’ multiple fibroids. The uterus was mapped ultrasonographically using the laparoscopic ultrasound transducer. Next, under laparoscopic visualization, the needle handpiece was inserted into the abdomen three centimeters away from the ultrasound transducer insertion point. With careful coordination between visualization on the ultrasound and the laparoscope, the handpiece was directed into specific myomas for ablation with deployment of the needle arrays. This allowed emission of radiofrequency energy to shrink the myoma tissue. The exact depth and total ablation time is calculated for each deployment prior to initiation of the ablation. It is important to note that larger myomas may require multiple overlapping treatments due to their size and density. The procedure was performed in an outpatient setting with an estimated blood loss of less than 10 milliliters. Measurements and Main Results N/A Conclusion Laparoscopic radiofrequency ablation for very large multi-fibroid uteri can be successfully performed under ultrasound guidance as a uterine conserving method to treat symptomatic fibroids. The technique has many advantages when compared to other surgical techniques used to treat fibroids, including minimal blood loss, decreased post-operative pain, shorter recovery time, and a potentially narrower learning curve given that advanced laparoscopic suturing skills are not required.

Complications Associated with Cesarean Scar Ectopic Pregnancies

Study Objective The aim of this study is to present and discuss complications that were encountered during the surgical management of cesarean scar ectopic pregnancies. Design This is a video case series of two patients with cesarean scar ectopic pregnancies. Setting Both patients were positioned in dorsal lithotomy position prior to the start of the surgeries. A primary surgeon and assistant were placed on either side of the patient. Patients or Participants Two patient case series. Patients with a diagnosis of cesarean scar ectopic pregnancy desiring laparoscopic hysterectomy were recruited. Interventions Both patients received total laparoscopic hysterectomies for the management of their cesarean scar ectopic pregnancies. Measurements and Main Results In both cases significant adhesions were noted leading to complications including uterine artery laceration, bleeding from the cesarean scar ectopic pregnancy implantation site and inadvertent cystotomy. We present in this video dissection techniques used and management of these complications. Conclusion Cesarean scar ectopic pregnancies can be difficult to managesurgically as they are often associated with significant adhesions between the anterior abdominal wall, bladder and uterus. Care should be taken to avoid inadvertent laceration of these structures when managing these cases surgically. In these surgeries, surgeons should feel comfortable with methods of laparoscopic suturing to control bleeding and repair any injuries.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations.

The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills. Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups. Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups. Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome.

Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported. A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. The mean operating time per side was 33.9 ± 6.8min and the average hospital stay was 1.9 ± 0.3days. Blood loss was 20cc ± 10cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079).Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001). A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Airway management with I-gelTM for ambulatory laparoscopic inguinal hernia repair in children; a retrospective review of 230 cases

Background: Inguinal hernia is one of the most common conditions presented for surgical repair in children and laparoscopic approaches are increasingly performed. Previous studies have shown safety and efficacy in the use of supraglottic devices (SGD) as an alternative to tracheal intubation, which fits particularly well with outpatient anesthesia.&#x0D; Methodology: we conduct a retrospective observational study, collecting data from the electronic anesthetic form, from all patients aged 0 to 17 y who underwent ambulatory laparoscopic percutaneous internal ring suturing between February 2015 and August 2019, if I-gelTM was used to airway management.&#x0D; Results: We found 230 patients meeting the inclusion criteria. The mean age was 5.2 y old, mean weight 20.1 kg. All patients were ASA I (n=203) or ASA II (n=27). The mean surgery duration was 38 minutes. We found 4 respiratory adverse events, three bronchospasms, and one laryngospasm, managed in the operating room. Ninety percent of the surgeries were performed without neuromuscular blockade.&#x0D; Conclusion: I-gelTM was a safe, effective, and convenient alternative to airway management to laparoscopic inguinal hernia repair in the ambulatory setting. According to available literature, our practice did not represent an increased risk for the studied respiratory events. SGD obviates the need for neuromuscular blockade.&#x0D; Key words: I-gel; Supraglottic devices; Laparoscopy; Inguinal hernia repair; Pediatrics; Anesthesia, ambulatory&#x0D; Citation: Hipólito C, Vieira V, Antunes V, Alves P, Rodrigues A, Santos MJ. Airway management with I-gelTM for ambulatory laparoscopic inguinal hernia repair in children; a retrospective review of 230 cases. Anaesth. pain intensive care 2020;24(5):&#x0D; Received: 18 February 2020, Reviewed: 5 August, 6 September 2020, Accepted: 11 September 2020

The application of single-port laparoscopic percutaneous internal ring suture for the management of indirect inguinal hernia in female adults

As most of the female inguinal hernias are of indirect type, we conducted this retrospective study to evaluate whether the single port laparoscopic percutaneous internal ring suture is feasible for the management of indirect inguinal hernia in female adults. From April 2016 to August 2019, there were 31 female adults who were diagnosed with inguinal hernias and received laparoscopic inspection at our surgical department. One patient who was finally diagnosed as an encysted hydrocele was excluded from the statistic study. All the 30 cases were of indirect type with a total of 35 single port laparoscopic percutaneous internal ring sutures performed. The median age was 38 years (range 20–88 years). The number and percentage of patients with right, left and bilateral hernias were 17 (56%), 11 (37%) and 2 (7%) respectively. Three contralateral patent processi vaginalium and 1 occult femoral hernia were found during operation. The percentages of the respective classifications according to the European Hernia Society system for the 35 PIRSs were L1: 40%, L2: 49%, and L3: 11%. The average operation time was 18 min for unilateral and 30 min for bilateral hernias. There were 1 recurrence and 1 chronic postoperative inguinal pain. Both had their symptoms and signs resolved after reoperation. The mean follow-up period was 13.6 months. We concluded that the single-port laparoscopic percutaneous internal ring suture is feasible for the management of indirect inguinal hernia in female adults.

Laparoscopic repair of a Bochdalek hernia in an elderly patient: a case report with a review from 1999 to 2019 in Japan

BackgroundA Bochdalek hernia (BH) is a congenital defect of the diaphragm that generally presents in the newborn as life-threatening cardiorespiratory distress. In contrast, the diagnosis of a BH in adults is rare. Surgical repair for adult BH is recommended, but the optimal surgical method remains unclear.Case presentationA 75-year-old woman presented with progressive dyspnea and back pain, and a diagnosis of BH was made based on chest X-ray and computed tomography. Laparoscopic evaluation revealed a defect in the left posterior attachment of the diaphragm, and a left-sided BH without hernia sac was diagnosed. Parts of the stomach, small intestine, colon, pancreas, and spleen had prolapsed into the left thoracic cavity, without ischemic change, and these herniated organs were reduced to the abdominal cavity. A direct closure of the hernia orifice was possible by the laparoscopic suture technique using a mesh reinforcement. The patient made an uneventful recovery, and no recurrence was found in the 2-year follow-up.ConclusionA recently published study reviewing detailed cases of repair of adult BH from 1999 to 2019 identified 96 cases, including the present case. The number of reports on laparoscopic and/or thoracoscopic surgery for BH in adults has recently increased, and the approach for repairing BH should be selected carefully on a case-by-case basis.

Anorectal injury related to a personal watercraft: a case report and literature review

BackgroundDouche injury is a rare consequence of water recreation activities. Generally, this type of trauma occurs when people fall into the water in a sitting position during high-speed activities such as using a personal watercraft (PWC). Here, we report a rare case of anorectal injury caused by water jets from a PWC during sudden acceleration from rest.Case presentationA 21-year-old male passenger on a PWC fell off backward from the rear seat when the craft suddenly accelerated. He fell into the water in a supine position with his legs open, and the water jets of the PWC struck his perineum directly. Thereafter, bleeding from the anus was seen, and he was transferred to our hospital. On physical examination, there was a deep laceration interrupting the external anal sphincter in the posterior rectal wall. Abdominal computed tomography revealed a full-layer perforation of the posterior rectal wall and leakage of feces into the extraperitoneal space, but intraperitoneal free air was not seen. Laparoscopic sigmoid loop colostomy and primary suturing of the sphincter and mucosa were performed. He did not have any complications and was discharged from our hospital 16 days after the surgery. His anal function was almost perfectly preserved, and his diverting colostomy was closed 4 months later.ConclusionAnorectal injuries related to PWCs can occur not only while traveling at high speeds, but also when suddenly accelerating from rest. A diverting colostomy should be performed for this type of trauma. In these trauma cases, clinicians must suspect complex and life-threatening anorectal injuries early.

Protocol for Randomised Controlled Feasibility Study Comparing Cruroplasty with Circumferential DynaMesh-HIATUS® Versus Suture-Only Repair for Large Hiatus Hernias

Laparoscopic fundoplication has become a standard surgical treatment for gastro-oesophageal reflux disease. Many of these patients also have a hiatus hernia that is repaired at the same time. However, suture-only repair of larger hiatus hernias has recurrence rates as high as 50%. Evidence on the effectiveness and safety of surgical mesh to reinforce hiatal repair compared with suture-only repair is currently lacking. This study aims to assess the feasibility of running a randomised controlled trial comparing the results of large hiatus hernia repair with DynaMesh-HIATUS® crural reinforcement versus standard suture repair alone. This is a single-centre, double-blind, parallel group randomised feasibility study. Forty patients with large hiatus hernia will be randomised to standard laparoscopic suture repair or suture repair with cruroplasty using the DynaMesh-HIATUS® circumferential mesh, with a 3-year follow-up period. Participants and assessors will be blinded to treatment allocation. Outcomes include trial process indicators (eligible participants, recruitment, and retention rates), surgical indicators (placement of mesh, operative complications, length of stay), adverse events, patient quality of life and symptom scores and mesh position after 1 year, and patient quality of life measures to 3 years. Feasibility will be assessed by rates of recruitment, retention, and successful surgical procedures. Clinical and patient-related outcomes for the two surgical methods will be described, and those most appropriate to include in a definitive trial identified. Correlation will be made between the position of the mesh on magnetic resonance imaging (MRI) and clinical outcomes. The DYNAMIC study will provide information to design and deliver a definitive randomised controlled trial of DynaMesh-HIATUS® cruroplasty compared with suture repair alone. https://doi.org/10.1186/ISRCTN76437720

Basic knowledge of and a small trick for atraumatic needle driving in laparoscopic suturing.

Highlight Although recent advances in robotic surgery have enabled more precise movements of the needle driver, a sophisticated laparoscopic suturing technique is still desired. Honda and colleagues describe the basic knowledge of and a small but useful trick for atraumatic needle driving in laparoscopic suturing, based on mechanistic considerations.

Laparoscopic Upper Colpectomy for VAIN III after Previous Total Hysterectomy

To demonstrate the feasibility of laparoscopic upper colpectomy for the treatment of vaginal intraepithelial neoplasia (VAIN) after previous total hysterectomy. Stepwise demonstration of the technique with narrated video footage. In 2014, our patient aged 60 years underwent a routine smear that reported severe dyskaryosis. This was treated with large loop excision of the transformation zone. Histopathology confirmed cervical intraepithelial neoplasia II, with positive ectocervical margins. The patient was counseled for both repeat large loop excision of the transformation zone and hysterectomy, opting for definitive surgery. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed in January 2015, completely excising the residual cervical intraepithelial neoplasiaII. A vault smear was performed in October 2015, reporting further severe dyskaryosis. The patient subsequently underwent examination under anesthesia and multiple upper vaginal mapping biopsies-identifying extensive VAIN III. The case was successfully managed by a laparoscopic upper colpectomy. When determining the area of VAIN to be excised, it can be useful to place a vaginal marker stitch; however, we chose to perform a colposcopy and apply acetic acid to help delineate the extent of the VAIN, immediately before laparoscopy. The right-sided pelvic sidewall dissection proved more extensive owing to the disease burden on that side. No intra- or postoperative complications occurred. The final histopathology confirmed a 65 × 35 × 8-mm upper colpectomy specimen with VAIN III and clear surgical margins. The patient has since had a normal vault smear and no recurrence to date. We highlight the importance of gaining early retroperitoneal access and developing the lateral pelvic spaces to identify the ureters and gain vascular control of the pelvis. We demonstrate an approach to safely developing the posthysterectomy vesicovaginal plane, with the aid of bladder filling. We used a McCartney tube (Kebomed UK, Cullompton, Devon) to facilitate colpotomy and closed the vagina using a laparoscopic suturing technique. We believe laparoscopic upper colpectomy offers definitive management of VAIN-a condition that otherwise has a propensity for recurrence and is hence often associated with multiple vaginal excisional procedures.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

ObjectiveTo assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.DesignProspective evaluation.SettingSimulation Center.Patient(s)Forty REI fellows.Intervention(s)Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.Main Outcome Measure(s)Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.Result(s)Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).Conclusion(s)An intensive surgical boot camp enhances surgical skill among REI fellows.

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.

New techniques in ventral hernia surgery – an evolution of minimally-invasivehernia repairs

Incisional ventral hernia occurs after almost every fourth laparotomy. Still, both simple suturing of the hernia defect and open mesh repair, lead to a high incidence of infections and recurrences. In recent years, we have observed a further evolution of operational techniques used in order to reduce the number of complications. The search for effective repair methods is currently going in two directions: on the one hand, techniques to reduce tissue tension in the suture line are being developed and disseminated (including modifications to the so-called Ramirez technique); on the other hand, minimally invasive techniques are introduced that allow placement of large synthetic meshes without the need for extensive tissue dissection using open repair. In the first group of presented techniques, emphasis is put on basics and access in the following repair method: original Ramirez technique, modified Ramirez technique, anterior component separation with periumbilical perforator-sparing, endoscopic anterior component separation and transversus abdominis release. In the second part of the manuscript, attention is drawn to the following hernia repair techniques: eTEP, reversed TEP, MILOS/eMILOS, stapler repair, TAPP, TARUP, TESLA, SCOLA, REPA, LIRA, IPOM, IPOM-plus. When choosing the optimal technique for a given patient, the surgeon should first of all be guided by technical feasibility, availability of materials, their own experience, as well as the characteristics of the patient and overall burdens. Nevertheless, surgeons undertaking reconstruction of the abdominal wall in the case of hernias should know different surgical accesses and individual spaces of the abdominal integument, in which a synthetic material may be placed. However, it should be emphasized that poor ergonomics of novel techniques, complex anatomy and complicated dissection of space, as well as the need for laparoscopic suturing in a difficult arrangement of tissue layers and in a narrow space, without a full triangulation of instruments, make these operations a challenge even for a surgeon experienced in minimally invasive surgeries.

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial

BackgroundUnsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.MethodsNovices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.ResultsForty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).ConclusionsRemote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.Trial registrationISRCTN 83733979