Laparoscopic Team Research Articles

Strangulated Paraesophageal Hernia Requiring Laparoscopic Total Gastrectomy

Introduction: Hiatal hernias are classified into four types.1 A type III hiatal hernia is a combination of types I and II where both the fundus and gastroesophageal junction herniate through the hiatus.2 Elective surgical repair is indicated for all types of symptomatic paraesophageal hernias. Emergency repair is indicated when a patient presents with associated obstruction, strangulation, uncontrolled bleeding, or perforation.3 In cases where gastric necrosis occurs, a gastrectomy may be required. A total gastrectomy can be performed either laparoscopically or open. A laparoscopic total gastrectomy has been shown to be a safe procedure with reduced length of stay but requires a well-trained laparoscopic team.4 This video illustrates a laparoscopic total gastrectomy for a necrotic stomach secondary to a gastric necrosis and perforation from an incarcerated paraesophageal hernia. Materials and Methods: A 74-year-old female presented to the emergency department with acute abdominal pain. CT of the abdomen and pelvis showed a type III hiatal hernia with intra-abdominal and intrathoracic free air. She was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, a large strangulated, necrotic, and perforated paraesophageal hernia involving >75% of the stomach was noted. The entire stomach was reduced with 4 cm of intra-abdominal esophagus. The distal esophagus was then transected. The duodenum was then transected distal to the pylorus. The gastric specimen was removed, and the patient was left in discontinuity because of multiple vasopressor requirements. The operation took 151 minutes with 75 mL of blood loss. Results: The patient was on multiple vasopressors throughout the case and transferred to the surgical intensive care unit for postoperative management. The patient underwent renal replacement therapy and was unable to be weaned from vasopressors. She developed severe sepsis-induced coagulopathy and was not medically stable for re-exploration the ensuing day. The patient remained on intravenous antibiotics and antifungals throughout this time. Owing to escalation of care and lack of thoracic surgery at this facility, the patient was transferred to a tertiary center. Over the next week, the vasopressors were discontinued. Bilateral chest tubes and abdominal drains were placed by interventional radiology. On postoperative day 21 from the index case, there was a change in the volume and color of the chest tube output and a CT chest showed an esophageal stump blowout. She subsequently underwent a right video-assisted thoracoscopic surgery wherein a mediastinal abscess was encountered and the distal esophagus was necrotic requiring further resection. On postoperative day 26, she returned to the operating room for placement of jejunostomy feeding tube; however, the abdomen was diffusely frozen and intra-abdominal abscesses were encountered. She remains in discontinuity without enteral access and was discharged to a long-term acute care facility. Conclusion: Strangulated paraesophageal hernias are rare but have significant morbidity when they occur. This case reinforces the need to repair paraesophageal hernias electively before severe complications. Despite the severity of the case, a laparoscopic approach was effective in performing a total gastrectomy in the acute phase and achieving source control. No competing financial interests exist. Runtime of video: 7 mins 4 secs Source: The source of the study was obtained from Trumbull Regional Medical Center. Authors have no conflict of interests or obligations from Trumbull Regional Medical Center. Patient Consent: Authors have received and archived patient consent for video recording and publication in advance of video recording of the procedure.

Impact of background music on the performance of laparoscopy teams

BackgroundAcoustic conditions in the operating room have different impacts on surgeon’s performance. Their effects on the performance of surgical teams are not well documented. We investigated if laparoscopic teams operating under pleasant acoustic conditions would perform better than under noisy conditions.MethodsWe recruited 114 surgical residents and built 57 two-person teams. Each team was required to perform two laparoscopic tasks (object transportation and collaborative suturing) on a simulation training box under music, neutral, and noisy acoustic conditions. Data were extracted from video recordings of each performance for analysis. Task performance was measured by the duration of time to complete a task and the total number of errors, and objective performance scores. The measures were compared over the three acoustic conditions.ResultsA music environment elicited higher performance scores than a noisy environment for both the object transportation (performance score: 66.3 ± 8.6 vs. 57.6 ± 11.2; p < 0.001) and collaborative suturing tasks (78.6 ± 5.4 vs. 67.2 ± 11.1; p < 0.001). Task times in the music and noisy environments was subtracted to produce a music-noisy difference time. Pearson correlation coefficient analysis showed a significant negative relationship between the team experience score and the music-noisy difference time on the object transportation (r = − 0.246, p = 0.046) and collaborative suturing tasks (r = − 0.248, p = 0.044).ConclusionsAs to individuals, music enhances the performance of a laparoscopy team while a noisy environment worsens performance. The negative correlation between team experience and music-noisy difference time suggests that laparoscopy teams composed of experienced surgeons are less likely affected by an acoustic distraction than the noisy teams. Team resistance to acoustic distraction may lead to a new way for assessing team skills.

Familiarity of surgical teams: Impact on laparoscopic procedure time

BackgroundSurgical performance is a team effort. We examine whether the familiarity among laparoscopic team members will influence the procedure time (PT). MethodsA team familiarity score (TFS) and an Index of difficulty of surgery (IDS) was calculated for each of the 360 laparoscopic procedures. Simple linear, multiple linear regressions, and random forest regressions were used for data analyses. ResultsSimple linear regression shows for every 1% increase in TFS, PT decreases by about 0.24% (p < 0.001); 7% of PT variability can be explained by TFS alone. Multiple linear regression reported that 49% of PT variability can be explained when considering IDS, team size, and TFS as influencing factors. Random forest regression reported that 52% of PT variability can be explained by taking TFS, Team Size, Patient Age, and IDS into the model. ConclusionTeam familiarity makes a small but significant contribution to the enhancing of surgical team performance in laparoscopic procedure.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Synchronization of Pupil Dilations Correlates With Team Performance in a Simulated Laparoscopic Team Coordination Task.

Modern surgery crucially relies on teamwork between surgeons and assistants. The science of teamwork has been and is being studied extensively although the use of specific objective methodologies such as shared pupil dilations has not been studied as sufficiently as subjective methods. In this study, we investigated team members' shared pupil dilations as a surrogate for surgeon's team performance during a simulated laparoscopic procedure. Fourteen subjects formed dyad teams to perform a simulated laparoscopic object transportation task. Both team members' pupil dilation and eye gaze were tracked simultaneously during the procedure. Video analysis was used to identify key event movement landmarks for subtask segmentation to facilitate data analysis. Three levels of each teams' performance were determined according to task completion time and accuracy (object dropping times). The determined coefficient of determination (R2) was used to calculate the similarity in pupil dilations between 2 individual members' pupil diameters in each team. A mixed-design analysis of variance was conducted to explore how team performance level and task type were correlated to joint pupil dilation. The results showed that pupil dilations of higher performance teams were more synchronized, with significantly higher similarities (R2) in pupil dilation patterns between team members than those of lower performance teams (0.36 ± 0.22 vs. 0.21 ± 0.14, P < 0.001). Levels of pupil dilation synchronization presented among teams reflect differences in performance levels while executing simulated laparoscopic tasks; this demonstrated the potential of using joint pupil dilation as an objective indicator of surgical teamwork performance.

Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal cancer.

In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach. We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video. Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453min and median blood loss was 46g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation. The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.

Experience with a novel laparoscopic gynecologic curriculum in Haiti: lessons in implementation.

An estimated one-third of the world's burden of disease requires surgical treatment. In many high-income nations, a large proportion of critical surgical procedures are performed laparoscopically due to a number of advantages the technique offers. There is forward progress in the global surgery field to increase access to laparoscopic techniques in low and middle-income settings (LMIC), with potential benefits to both patients and surgeons. A week long laparoscopic surgery curriculum for surgeons and hospital staff was designed and implemented in a low-resource setting. An iterative design was used to adapt the curriculum on the ground. The local laparoscopic team was able to independently perform two laparoscopic procedures since the course was administered. Implementing laparoscopic surgery programs may be feasible in many LMIC settings. Access to this care may benefit patients. Lessons learned for the global laparoscopist are described.

The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair.

While the majority of the literature written concerning minimally invasive hiatal hernia repair involves laparoscopy, little has been written concerning the transition to a robotic technique. We present our experience, with a transparent analysis of data, with regard to the introduction of robotic paraesophageal hernia (PEH) repair by an experienced laparoscopic surgeon. We reviewed our first 30 consecutive patients who underwent robotic PEH over a 2-year period after the introduction of robotic surgery at our institution. Patients were divided into two groups: the early experience group (procedures performed within the first year of introduction of robotic technique, n = 13) and a late experience group (procedures performed in the second year, n = 17). All procedures were performed by a single experienced foregut surgeon. The mean operative time for the early group was significantly greater than for the late group, 184min versus 142min, respectively (p < 0.01). Four patients in the early group required conversion to open, while zero patients in the late group required conversion (p = 0.03). Patient demographics and complications did not differ significantly between the two patient populations. The early robotic hiatal hernia repair experience can be more difficult than expected, even in the hands of an experienced laparoscopic team. We identify several areas of improvement including patient positioning, operating room team training, and technical experience. This data can help other surgeons prepare for the transition to robotic foregut surgery.

Extending the Indication for Laparoscopic Surgery in Patients With Pan-Peritonitis.

There have been reports of favorable results in patients with peritonitis who underwent laparoscopic surgery. The present study evaluated the outcomes of laparoscopic surgery in patients with pan-peritonitis. We enrolled 148 patients who underwent open and laparoscopic surgery for pan-peritonitis between January 2015 and December 2017 at Hanyang University Guri Hospital. Patients with appendicitis or cholecystitis were excluded from this study because of the simplicity of the technique and the favorable postoperative prognosis. Surgical outcomes including open conversion, morbidity, mortality, risk, and prognostic factors were evaluated. During the study period, 125 patients (84.5%) underwent laparoscopic surgery. The conversion to open surgery occurred in 7 (5.3%) patients. In the laparoscopic surgery group, 27 patients (21.6%) experienced postoperative complications, and 6 died (4.8%). Multivariate analysis showed that age of older than 75 years was a risk factor for postoperative complications. Especially, preoperative shock (<90 mm Hg) and a longer time from symptom onset (over 2 d) to surgery were prognostic factors for postoperative mortality. On the basis of our results and experiences, we believe that laparoscopic surgery is applicable to surgery of pan-peritonitis. And, preoperative shock and longer time from onset are prognostic factors of mortality in laparoscopic group. Therefore, we are confident that careful patient selection and specialized laparoscopic team should be considered in order to have best results.

Using simulation to teach laparoscopic surgical skills – tips, pearls and pitfalls

Surgical training is radically changing in many countries worldwide. The traditional Halstedian model of time-bound apprenticeship is being replaced with competency-based learning surgical programmes. There has also been an increase in the use of simulation-based medical education (SBME) including the educational principles influencing the way that we acquire and maintain new surgical skills. These principles are not just unique to the surgical domain and can be applied to other procedural-based disciplines. Surgical SBME involves the acquisition of both technical and non-technical skills including; laparoscopic skills acquisition, basic surgical, emergency resuscitation, communication, leadership and team working skills. In technical skills acquisition laparoscopic surgery is ideally applicable to SBME. The skills utilised to safely perform this operative modality are unique and include altered depth perception, fulcrum effect, loss of haptic feedback, 2D to 3D realisation, fine motor skills and altered tissue handling. The educational techniques used to teach these skills in a simulation environment will be discussed, as well as, their adaptability to other procedural skills acquisition. The creation, validation and application of low-cost simulators will also be discussed and their application worldwide into different settings.

Introducing laparoscopic total gastrectomy for gastric cancer in general practice: a retrospective cohort study based on a nationwide registry database in Japan.

Although laparoscopic total gastrectomy (LTG) is considered a technically demanding procedure with safety issues, it has been performed in several hospitals in Japan. Data from a nationwide web-based data entry system for surgical procedures (NCD) that started enrollment in 2011 are now available for analysis. A retrospective cohort study was conducted using data from 32,144 patients who underwent total gastrectomy and were registered in the NCD database between January 2012 and December 2013. Mortality and morbidities were compared between patients who received LTG and those who underwent open total gastrectomy (OTG) in the propensity score-matched Stage I cohort and Stage II-IV cohort. There was no significant difference in mortality rate between LTG and OTG in both cohorts. Operating time was significantly longer in LTG while the blood loss was smaller. In the Stage I cohort, LTG, performed in 33.6% of the patients, was associated with significantly shorter hospital stay but significantly higher incidence of readmission, reoperation, and anastomotic leakage (5.4% vs. 3.6%, p<0.01). In the Stage II-IV cohort, LTG was performed in only 8.8% of the patients and was associated with significantly higher incidence of leakage (5.7% vs. 3.6%, p<0.02) although the hospital stay was shorter (15days vs. 17days, p<0.001). LTG was more discreetly introduced than distal gastrectomy, but remained a technically demanding procedure as of 2013. This procedure should be performed only among the well-trained and informed laparoscopic team.

Evaluation of oncological adequacy of laparoscopic distal gastrectomy with special attention to lymph node dissection: a comparison with conventional open gastrectomy.

Laparoscopic distal gastrectomy (LDG) with lymphadenectomy has been revealed to be a useful treatment for early gastric cancer but oncological adequacy is controversial. To assess the quality of lymphadenectomy, we evaluated the number of dissected lymph nodes and the non-compliance rate (defined as an absence of nodal tissue at a node station that should have been resected) and compared the data obtained from 102 patients treated by LDG with those from 90 patients treated by open distal gastrectomy (ODG). The numbers of nodes of Categories 1 and 2, which correspond respectively to perigastric and retroperitoneal nodes, did not differ significantly between the LDG group and the ODG group. In the LDG group compared to the ODG group, there were significantly more right paracardial nodes (No. 1) but there were significantly fewer infrapyloric nodes (No. 6). However, the difference in infrapyloric nodes (No. 6) became insignificant when we re-analyzed and compared the ODG group and the patients (n=42) whose LDGs were performed by two experienced laparoscopic surgeons. The curability of gastric cancer on LDG was almost equivalent to that of ODG from the viewpoint of lymph node dissection, if the LDG is performed by two experienced laparoscopic surgeons. These data suggested that LDG with lymphadenectomy could possibly be adopted for advanced gastric cancer treatment under proper quality control, such as that provided by an experienced laparoscopic team.

Collaborative performance in laparoscopic teams: behavioral evidences from simulation.

To examine the frequency of movement de-synchronization between a surgeon and assistant in a laparoscopic simulation task, and test whether it can be a valid behavior marker for team performance. Fourteen subjects formed a total of 22 dyad teams. Each team performed a laparoscopic task where the camera driver navigated a laparoscope for the operator to transport a plastic cylinder between targets. Key movement landmarks were annotated from recorded surgical videos and were used to identify team behaviors and performance. Task completion time, number of movement de-synchronization, and errors (cylinder drops) were compared over 3 performance groups (elite, intermediate, poor) and 2 types of movements (on-site manipulation vs. position-shifting. Task completion time of elite teams was shorter than intermediate and poor teams (33.3 vs. 66.8 vs. 141.2s, P<0.001). Elite teams made fewer errors (0.1 vs. 0.5 vs. 0.9, P=0.063) and recorded fewer numbers of de-synchronization than poor teams (2.9 vs. 3.0 vs. 4.9, P=0.009). We also found that the on-site manipulation took longer task time (113.5 vs. 51.2s, P<0.001) and recorded fewer de-synchronization (0.6 vs. 5.3, P<0.001) than position-shifting tasks. However, there is no significance in the measure of errors (P=0.029). Interaction effects were revealed between performance groups and two movement types in task time (P=0.010) and movement de-synchronization (P=0.003). Video analysis is a useful tool for identifying team behaviors during surgery. Movement de-synchronization between surgeons and assistant reveals team cooperation in laparoscopic procedure. The evidence where de-synchronization occurred frequently during the position-shifting tasks rather than during the on-site manipulation suggests team collaborative behaviors can be affected by different task requirements.

Feasibility and safety of laparoscopic nephrectomy in uremic patients with end-stage renal disease.

The purpose of this study was to analyse the feasibility and safety of laparoscopic radical nephrectomy (LRN) vs. open radical nephrectomy (ORN), in terms of perioperative and postoperative outcomes, in uremic patients. Between September 2007 and December 2013, 19 patients with end-stage renal disease (ESRD), who underwent LRN or ORN for chronic pyelonephritis, renal calculi, hydronephrosis, renal tumors, complicated cyst, or associated polycystic kidney, were retrospectively analysed. All patients with complete preoperative clinical and intraoperative parameters, including age at surgery, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, surgical technique, operation time, complications, were available for further analyses. The 30-day complication rate in both groups was retrospectively review and graded according to the modified Clavien System in five grades. Overall, nine (47.3%) vs. 10 (52.7%) patients underwent LRN vs. ORN, respectively. The mean ASA score (2.7 ± 0.8 vs. 2.9 ± 0.7) did not show statistically significant differences in both groups (p = 0.632). None of the patients in G1 was converted to open surgery for intraoperative complications or CO2 retention. The estimated blood loss was 223 ± 155 mL in G1 and 455 ± 134 mL in G2 (p&lt;0.005). Both groups were comparable with regard to mean operation time. The mean hospital stay was 5.95 ± 1.85 days in G1 and 8.10 ± 1.67 days in G2 (p&lt;0.001). The present study revealed that laparoscopic surgery in uremic patients might be performed safely under the expertise of an experienced laparoscopic team. This surgical technique is a minimally invasive treatment, reduces blood loss, shortens postoperative hospital stay, minimizes wound pain, and encourages an earlier return to normal activity.

Power Doppler flow mapping and four-dimensional ultrasound for evaluating tubal patency compared with laparoscopy

ObjectivesTo study the accuracy of four-dimensional (4D) ultrasound and power Doppler flow mapping in detecting tubal patency in women with sub-/infertility, and compare it with laparoscopy and chromopertubation. Study designA prospective study. The study was performed in the outpatient clinic and infertility unit of a university hospital. The sonographic team and laparoscopic team were blinded to the results of each other. Women aged younger than 43 years seeking medical advice due to primary or secondary infertility and who planned to have a diagnostic laparoscopy performed, were recruited to the study after signing an informed consent. All of the recruited patients had power Doppler flow mapping and 4D hysterosalpingo-sonography by injecting sterile saline into the fallopian tubes 1 day before surgery. Registering Doppler signals, while using power Doppler, both at the tubal ostia and fimbrial end and the ability to demonstrate the course of the tube especially the isthmus and fimbrial end, while using 4D mode, was considered a patent tube. ResultsOut of 50 recruited patients, 33 women had bilateral patent tubes and five had unilateral patent tubes as shown by chromopertubation during diagnostic laparoscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for two-dimensional power Doppler hysterosalpingography were 94.4%, 100%, 100%, 89.2%, and 96.2%, respectively and for 4D ultrasound were 70.4%, 100%, 100%, 70.4%, and 82.6%, respectively. ConclusionsFour-dimensional saline hysterosalpingography has acceptable accuracy in detecting tubal patency, but is surpassed by power Doppler saline hysterosalpingography. Power Doppler saline hysterosalpingography could be incorporated into the routine sub-/infertility workup.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status.

To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors. A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach. The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described. Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

Surgical team composition differs between laparoscopic and open procedures.

Performing laparoscopic procedures requires different skill sets and team dynamics compared with open procedures. We evaluated team composition and procedure time between these two surgical approaches using data collected from hospitals in the United State and Canada. A total of 1,260 general surgical cases were reviewed retrospectively, recording the number of operation personnel, procedure complexity, and the procedure time. Laparoscopic procedures (n = 930), on average, had a higher procedure difficulty coding which led to a longer procedure time and involved more people in the surgical team than open procedures (n = 330). When we selected cases with matched procedure difficulty coding, laparoscopic procedures (n = 450) still required longer procedure times and involved more operative personnel than open procedures (n = 92). Increased laparoscopic team size and procedure time must be influenced by factors other than case difficulty. The factors may derive from inherent complexity of the surgical setting and team dynamics unique to laparoscopic procedures.

Influence of a short term camera navigation training on laparoscopic performance and team cooperation in a virtual reality setting

Influence of a short term camera navigation training on laparoscopic performance and team cooperation in a virtual reality setting

Development of urologic laparoscopy in Germany, Austria, and Switzerland: a survey among urologists

Laparoscopy introduction has dramatically changed urology. Novel techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), might also have substantial influence. This 2012 survey evaluated present laparoscopy use, its appraisal among urologic surgeons, laparoscopy training, and use of new techniques. Results were compared to the previous surveys, demonstrating the 10-year development of laparoscopy. A detailed questionnaire regarding demographic data, laparoscopy use, attitudes concerning laparoscopy, and novel techniques was send to 424 departments in Germany, Austria, and Switzerland. Procedures performed in 25 indications were quantitatively evaluated. The response rate was 63 % (269). Eighty-six percent of the respondents reported performing laparoscopy, compared to 54 % in 2002. Only 16 % expected economic advantages with laparoscopy, whereas 67 % expected shorter hospitalization. Seventy percent of responders anticipated comparable functional and oncological results between laparoscopic procedures and open surgery. Slow learning curves (81 %) and insufficient training facilities (32 %) were reported to impair laparoscopic surgery. On average, laparoscopic and non-laparoscopic surgical teams consisted of 2.5 and 3.5 members, respectively. LESS procedures were performed at 15 % of institutions. Twenty-two percent of respondents considered NOTES techniques valuable for future urology. Few indications (laparoscopic prostatectomies or nephrectomies) were performed frequently in specialized centers, and the rapidly increasing procedure numbers observed between 2002 and 2007 had dropped to a mild accretion. The results demonstrate broad acceptance of laparoscopy in German urologic surgery, depict the need for structured training facilities, and indicate limited impact of novel techniques (LESS and NOTES). The survey demonstrates the 10-year development of urologic laparoscopy and the broad acceptance of laparoscopic techniques.

Evidence-based laparoscopic appendectomy practice requires national database studies

Dear Editor, As the article by Saia et al. [1] indicates, administrative databases are useful in comparing different surgical techniques: randomized, controlled trials are difficult to realize, require large sample sizes, and are mostly subject to blinding biases. The results demonstrated in this study contribute to the discussion around data published in two surveys concerning dissemination of laparoscopic appendectomy (LA) in Italy, commissioned by two different scientific surgical societies [2, 3]. The overview provided of the situation, 7 years after these initial results, confirm the increasing rate of LAs, particularly in fertile women. The use of LA is undoubtedly evidence based; no hard evidence confirms its application to subgroups different from premenopausal women, where the rate of differential diagnoses, after exploratory laparoscopy, is quite high. A Cochrane review by Sauerland et al. [4] emphasizes the poor quality of evidence in support of the advantages of an all-comers policy for LA. Similarly, the noted trend of performing fewer appendectomies can be due to the increasing application of antibiotic therapy to uncomplicated cases, which can be effective in most patients and can help avoid the need for surgery, as proved in a recent meta-analysis [5]. The major concern for the surgeon and the patient in the dissemination of LA has been the suspected increase in the rate of postoperative intra-abdominal abscesses, which might require a prolongation of the hospital stay or the need for a second surgery; thus, it would be interesting to retrieve from the Veneto regional database the number of readmissions, so as to ascertain the real entity of this problem and its trend over the 8-year period. More recent reports have downplayed this complication [6], but the problem remains unresolved. Today, surgical training and standardization of the technique seem of utmost importance. Surgeon training is a fundamental issue, and it must be analyzed, in the existing health care systems, on the basis of a single ward or practice. One of the above-mentioned national surveys demonstrated that LA is performed in more than 90 % of the hospitals, but in low numbers (30–60 % of appendectomies) and by a selected laparoscopic team (\30 % of the surgeons working in the same practice), and is not related to case volume [2]. One of the answers to the extreme regional variability in the number of LAs performed might be standardization of the surgical approach through the wide adoption of surgical evidence-based guidelines that must be realized, implemented, and controlled by national scientific societies in tandem with a central health institute. This has been accomplished in Italy with the drafting of evidence-based guidelines and their diffusion through the scientific literature [7, 8] and through the Italian Istituto Superiore di Sanita (http://www.snlg-iss.it/cms/files/LG_ACOI_appendicectomia_ %20laparoscopica.pdf). This correspondence is written on behalf of ACOI (Associazione Chirurghi Ospedalieri Italiani) and SICE (Societa Italiana Chirurgia Endoscopica e Nuove Tecnologie).