Level Of Technical Difficulty Research Articles

Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

Policy Implementation Of Stunting Prevention In Kupang Tengah District, Kupang Regency

Kupang Regency is still one of the 3 regencies in the Province of NTT with a stunting rate of 24.14 percent or 7,207 children experiencing stunting based on data for the February 2022 weighing month and one of the locations for stunting 'pockets' in Kupang Regency so that the target for reducing the prevalence of stunting in Kupang Regency In 2022 the required 16.19 percent has not been fulfilled. Therefore, this study aims to analyze the implementation of stunting prevention policies in Kupang Tengah District, Kupang Regency. This research is a qualitative descriptive study using primary and secondary data sources collected through qualitative observation, qualitative interviews, qualitative documents and qualitative audio and visual materials. then the data that has been collected is analyzed using the data analysis steps proposed by Creswell (2016: 264-268). The results of the study show that (1) the level of technical difficulty is that there is still sectoral ego and coordination that is not going well, the behavior of the target group has not complied with the policy and the proportion of the target group is relatively small to the total population. (2) The contents of the policy are clear but the implementation is bad (bad execution) and the allocation of resources is minimal. (3) environmental variables from the implementation of policies that are constrained by social, economic and technological conditions but have the support of higher officials but are not supported at the lowest level of policy.

Analysis of 300 Total Laparoscopic Hysterectomy Cases Performed by The Same Surgeon

Aim: This study aimed to evaluate the results of 300 cases of total laparoscopic hysterectomy (TLH) performed by the same surgeon.
 Material and methods: During the study period, a total of 300 TLH operations were performed between January 2017 and December 2018. Demographic characteristics, indications of hysterectomy, uterine weights, intra-operative and post-operative complications, duration of the operation, length of hospital stay, blood loss of patients, visual analogue scores and amount of analgesics needed were retrospectively evaluated. Complications were analysed and compared with literature.
 Results: Parameters analysed for 300 patients included in the study were as follows: mean age 47.82 ± 6.18 years, mean parity 3.4 ± 2.0 (0–11), BMI 27.41 ± 4.36 (kg/m²), mean uterine weight 367.67 ± 266.21 g (50–1600 g), mean operative time 89.07 ± 37.94 min (30–240 min), mean hospital stay 54.37 ± 21.95 h (24–168 h) and total complication rate 28 (9.3%). Conversion to open surgery was required in 29 (9.7%) patients. The level of technical difficulty and existence of prior abdominal surgery were associated with a higher risk of complications and conversions to laparotomy.
 Conclusion: Total laparoscopic hysterectomy is a well-designed surgical procedure for the management of benign gynaecological conditions, and after adequate training, it seems to be a safe and effective procedure for patients.

Surgical management of Mirizzi syndrome during the pandemic in a COVID 19 referral center: Report of a case from a developing country

>Mirizzi syndrome (MS) is a rare complication of gallstone disease. Surgical management may be complex, depending on the type of Mirizzi, and may range from simple cholecystectomy to a hepaticojejunostomy. A 39-year-old female diagnosed previously to have gallstones was admitted in the Philippine General Hospital (PGH), a tertiary COVID 19 referral center presenting with obstructive jaundice, right upper quadrant pain and fever. Hepatobiliary ultrasonography demonstrated a markedly distended gallbladder with a stone at the Hartmann's pouch. A diagnosis of Mirizzi syndrome with cholangitis was made. The patient was managed with broad spectrum antibiotics and scheduled for surgery. No further imaging or endoscopy was requested due to the limitations brought about by the pandemic. Upon a negative COVID 19 polymerase chain reaction (COVID 19 PCR) test result she underwent surgery, subtotal cholecystectomy, intraoperative cholangiography, and choledochoplasty. No perioperative complications were noted. This patient was managed with the goal of providing excellent patient care while limiting risks from COVID 19 both to the patient and the health care team. This case demonstrates the need to address issues brought about by the pandemic resulting in limitations in resources, added risk of morbidity to patients, and increased level of technical difficulty particularly in biliary surgery.

The expanded endoscopic endonasal approaches for the skull base

Background: Endoscopic endonasal approach (EEA) for skull base surgery (SBS) is a significant modification of the current practice. Methods: We reviewed our experience at the University of Pittsburgh with EEAs for 800 patients from 1998 to July 2007. Results: Modular approaches to multiple pathologies of the skull base were designed totally based on intrinsic anatomy. Stages of training were established based on the level of technical difficulty and potential risk of vascular and neural injury. Five levels were defined in an incremental manner. Conclusions: Practice standardization with modular, incremental training is projected to facilitate the gaining of knowledge and skills to safely master EEAs for SBS in an organized manner. We suggest adherence to the systematic acquisition of endoscopic skills, to work as an integrated team of surgeons and to have a thorough perspective of conventional SBS and endoscopic surgery. Therefore, the choice of approach must be a specific function of the anatomy and pathology rather than the surgeon’s bias or lack of experience with alternative approaches.

Comparison of Laparoscopic Versus Vaginal Salpingo-Oophorectomy During Vaginal Hysterectomy

Objective: The aim of this study was to compare intraoperative and postoperative outcomes of two routes of salpingo-oophorectomy. Materials and Methods: Forty-two women undergoing vaginal hysterectomy were randomly assigned to 2 groups (1:1): group 1, laparoscopic oophorectomy with vaginal hysterectomy; or group 2, vaginal hysterectomy with vaginal oophorectomy. Outcome measures were operating time, blood loss, technical difficulty, intraoperative and postoperative complications, postoperative pain, and discharge time. Results: Vaginal oophorectomy was associated with a shorter operating time than laparoscopic oophorectomy at 37.06 ± 10.16 minutes (95% confidence interval [95% CI]: 32.36–41.75) and 20.75 ± 5.56 minutes (95% CI: 18.31–23.18), p = 0.001, in groups 1 and 2, respectively. The mean operating time for hysterectomy was similar in both groups at 48.06 ± 10.709 minutes for group 1 and 49.25 ± 11.318 minutes for group 2, p = 0.746. No statistically significant difference was noted for blood loss, level of technical difficulty, intraoperative or postoperative complications, postoperative pain, and discharge time. Conclusions: Vaginal and laparoscopic routes of oophorectomy can be used during vaginal hysterectomy. The vaginal route is a better option, with shorter operating time, feasibility with regional anesthesia, and a comparable surgical outcome to laparoscopy. When salpingo-oophorectomy cannot be completed vaginally, laparoscopic oophorectomy can be performed. (J GYNECOL SURG 32:220)

Spectral reconstruction of dental X-ray tubes using laplace inverse transform of the attenuation curve

Abstract In this work, a spectral reconstruction methodology for diagnostic X-ray, using Laplace inverse transform of the attenuation, was successfully applied to dental X-ray equipments. The attenuation curves of 8 commercially available dental X-ray equipment, from 3 different manufactures (Siemens, Gnatus and Dabi Atlante), were obtained by using an ionization chamber and high purity aluminium filters, while the kVp was obtained with a specific meter. A computational routine was implemented in order to adjust a model function, whose inverse Laplace transform is analytically known, to the attenuation curve. This methodology was validated by comparing the reconstructed and the measured (using semiconductor detector of cadmium telluride) spectra of a given dental X-ray unit. The spectral reconstruction showed the Dabi Atlante equipments generating similar shape spectra. This is a desirable feature from clinic standpoint because it produces similar levels of image quality and dose. We observed that equipments from Siemens and Gnatus generate significantly different spectra, suggesting that, for a given operating protocol, these units will present different levels of image quality and dose. This fact claims for the necessity of individualized operating protocols that maximize image quality and dose. The proposed methodology is suitable to perform a spectral reconstruction of dental X-ray equipments from the simple measurements of attenuation curve and kVp. The simplified experimental apparatus and the low level of technical difficulty make this methodology accessible to a broad range of users. The knowledge of the spectral distribution can help in the development of operating protocols that maximize image quality and dose.

Complications of laparoscopic gynecologic surgery.

Background and Objectives:To analyze the frequency of complications during laparoscopic gynecologic surgery and identify associated risk factors.Methods:A descriptive observational study was performed between January 2000 and December 2012 and included all gynecologic laparoscopies performed at our center. Variables were recorded for patient characteristics, indication for surgery, length of hospital stay (in days), major and minor complications, and conversions to laparotomy. To identify risk factors and variables associated with complications, crude and adjusted odds ratios were calculated with unconditional logistic regression.Results:Of all 2888 laparoscopies included, most were procedures of moderate difficulty (adnexal surgery) (54.2%). The overall frequency of major complications was 1.93%, and that of minor complications was 4.29%. The level of technical difficulty and existence of prior abdominal surgery were associated with a higher risk of major complications and conversions to laparotomy.Conclusion:Laparoscopic gynecologic surgery is associated with a low frequency of complications but is a procedure that is not without risk. Greater technical difficulty and prior surgery were factors associated with a higher frequency of complications.

LINX™ Reflux Management System: magnetic sphincter augmentation in the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), commonly manifested by heartburn or regurgitation, is a chronic, progressive condition in which failed sphincter function allows the contents of the stomach to reflux into the esophagus, the airways and the mouth. Chronic GERD affects 10% of Western society. The majority of patients receive adequate relief from proton pump inhibitors, but up to 40% have incomplete relief of symptoms that cannot be addressed by increasing the dose of medications. The laparoscopic Nissen fundoplication is the surgical gold standard; however, the level of technical difficulty and its side effects have limited its use to less than 1% of the GERD population. These factors have contributed to the propensity of patients to persist with medical therapy, even when inadequate to control symptoms and complications of the disease. Consequently, a significant gap in the treatment continuum for GERD remains evident in current clinical practice. The LINX™ Reflux Management System (Torax Medical) is designed to provide a permanent solution to GERD by augmenting the physiologic function of the sphincter barrier with a simple and reproducible laparoscopic procedure that does not alter gastric anatomy and can be easily reversed if necessary.

Celebrating Hoover Dam: The Majesty of Hoover Dam

The design and construction of Hoover Dam constituted a feat unlike any that had been previously accomplished; in its sheer size, scope, and level of technical difficulty, the structure surpassed expectations and set world records. And the history of its creation is replete with fascinating stories about the men, the machines—and the engineering—that made it possible.

Rigid Stabilization of Partial Incongruous Lisfranc Dislocations: A Cannulated Solid Screw Technique

For several years, there has been much controversy over the optimal form of fixation in the operative treatment of Lisfranc injuries. Both cortical and cannulated screws have been widely used in the treatment of these injuries. The level of technical difficulty and reproducible accuracy of the cannulated screw system has gained much popularity. In comparison, the rigid stability of cortical screws appears more favorable. The authors present a cannulated technique utilizing a single 4.0 mm cortical screw (Synthes USA Paoli, Pa.). In Lisfranc injuries with partial incongruity, this method allows precise screw placement while maintaining rigid solid screw stabilization. The technique is minimally invasive, provides anatomical restoration and allows early return to functional activity.

Acquisition of Surgical Skills for Endonasal Skull Base Surgery: A Training Program

Endonasal surgery represents a radical change in the practice of cranial base surgery and requires the acquisition of new knowledge and surgical skills. The optimal training program for surgeons has not been established. We reviewed our experience with endonasal cranial base surgery from 1998 to 2006 to develop a training plan for the acquisition of surgical skills. It consists of a modular and incremental approach to endonasal skull base surgery that is designed to train surgeons to function as a team, learn endoscopic skull base anatomy, and develop fundamental endoscopic skills. Stages of training are established for the otolaryngologist-head and neck surgeon and the neurosurgeon that are based on level of technical difficulty, potential risk of vascular and neural injury, and unfamiliar endoscopic anatomy. Mastery of each level is recommended before attempting procedures at a higher level. Standardization of training and the adoption of a modular, incremental training program are expected to facilitate the training of endonasal surgeons in both surgical specialties. Adherence to such a program during the growth phase of endoscopic skull base surgery may decrease the risk of complications as the surgeon's knowledge and surgical expertise develop.

Endoscopic Submucosal Dissection for Large Colorectal Tumors

Endoscopic Submucosal Dissection for Large Colorectal Tumors Takashi Toyonaga, Eisei Nishino, Akira Hayashibe, Takashi Hirooka Background: The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of large colorectal tumors. However, ESD is associated with a high level of technical difficulty and a high incidence of complications. In our department, ESD has been applied to lesions larger than 20 mm in diameter since June 2002, and we have obtained good results by choosing therapeutic instruments according to the situation. Methods: We studied 102 colorectal lesions in 98 patients (62 adenomas, 29 intramucosal cancers and 11 submucosal cancers) undergoing ESD in our department between June 2002 and November 2004. The locations: 13 lesions in the cecum, 28 in the ascending colon, 11 in the transverse, 4 in the descending, 15 in the sigmoid, and 31 in the rectum. Resection method: Erbotome ICC 200 was used for a electro-surgical unit, and a 4-mm length attachment was put on the endoscope tip in order to treat as below. Fourfold diluted hyaluronate sodium was locally injected into the submucosal layers, and the marginal mucosa around the lesions were incised with a Flex knife. Then, a Flex knife was mainly used, but a precutting knife for fibrotic targets and a Hook knife for the situations that muscle layers were located in front were appropriately combined in order to dissect the submucosal layers. When it was difficult to maintain the good endoscopic view, a small caliber-tip transparent hood was used. Results: The diameter of tumors: 13-104 mm (median 28 mm), the diameter of resection specimens: 20-114 mm (median 38 mm), En-bloc and complete resection rate: 96.1% (98/102). With 4 lesions (3.9%) for which en-bloc resection could not be performed, complete fractionated resection was performed after mucosal incision of the entire circumference. Operation time: 16-248 min. (median 42 min). Complications: intra-operative perforation 2.0% (2/102), delayed perforation 1.0% (1/102). The intra-operative perforations were shaped like a pinhole and were conservatively cured by clipping. The delayed perforation required surgery, and it was considered from the resection specimen that the perforation was due to necrosis of the muscle layer by electric current. Intra-operative bleeding with difficulty in hemostasis and post-operative bleeding requiring hemostasis were not observed. Conclusions: We obtained good results in resection by using ESD for large colorectal tumors. Combined therapeutic instruments were useful.

Inequity in the price of physician activity across surgical procedures

Objectives: A rational payment system is being sought in Japanese health care—one that accurately reflects the required time and the level of technical difficulty when valuing physician activity. The objective of this study is to examine the current surgical payment system in Japan by clarifying the hourly values allocated to physician activity. Methods: This study focused on the 22 surgical procedures most frequently registered in our study database of administrative data gathered from 11 teaching hospitals in Japan. The current fee-for-service reimbursement system does not formally define which cost components surgical fees cover. It was therefore necessary for us to examine directly each reimbursement item to determine which component it represented. Next we examined the current system from the following viewpoints: (1) variation in the hourly values allocated to physician activity, for an individual surgeon or a surgical team, among types of surgery by using the actual data; (2) the association between the hourly values and the operation time or the level of technical difficulty. Results: The hourly values allocated to physician activity were low (US$ 61.0 and 121.5 per surgeon: means of case 1 and case 2 estimations). The hourly values varied inequitably among types of surgery (from US$ −28 to 237 and from US$ 6 to 328: ranges in the case 1 and case 2 estimations). When long surgeries were excluded, shorter surgeries tended to have higher hourly values. The association between the hourly values and the difficulty level was less clear and their variation was large even at the same difficulty level. Conclusion: In the current payment system, the surgical fee is deemed to include fee for physician activity as well as materials, equipment and so on. To develop a rational payment system, first, the scope of the surgical fee and that of the physician activity fee should be separated and clearly defined. Second, the latter should be modeled to reflect the manpower volume and the level of technical difficulty needed for each surgical procedure. Third, fees should be set by utilizing the cost estimates with empirical data.

Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data

Background: Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty. Methods: A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty. A retrospective pilot study was performed to assess ERCP outcomes at our institution according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period. Results: In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p < 0.05) and less likely to have associated complications (2% vs. 10%, p < 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p < 0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant). Conclusions: Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons. (Gastrointest Endosc 2000;51:535-9.)

The type & Screen for pre-transfusion compatibility testing: Experience in a major teaching hospital in Hong Kong

Since December, 1986, the conventional crossmatch (CXM) has been replaced by the Type S Screen (T&S) for pre-transfusipn compatibility testing at the Prince of Wales Hospital. In order to appraise the T&S system and its practicability in Hong Kong, we compared it with the CXM according to the following parameters: proficiency in detecting antibodies, issuing of blood in emergency, level of technical difficulty, crossmatch-transfusion (C/T) ratio, reagent cost, workload, and blood outdating We found that the frequency and specificities of red cell antibodies detected by T&S were comparable to those in previous years when CXM was used. The T&S and CXM were also comparable in the issuing of blood during emergencies, and in the level of technical difficulty. The T&S reduced the C/T ratio from 3.25 in 1986 to 1.53 in 1988. The T&S entailed additional reagent cost, but saved on technologist’s workload. The main contribution of T&S was the dramatic reduction of outdated blood, from 1151 units in 1987 to 89 units in 1988.