Laparoscopic parastomal hernia repair using a nonslit mesh technique.

BACKGROUND: The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. METHODS: A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. RESULTS: A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence. CONCLUSION: On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) in patients with recurrent reflux after antireflux surgery: can surgery be avoided?

BACKGROUND: Recurrent reflux following antireflux surgery (ARS) can be difficult to manage, especially in patients who also fail medical management. In these patients, redo ARS remains the only treatment option. Endoscopic radiofrequency energy delivery to the lower esophageal sphincter (the Stretta procedure; Stretta, Curon, Sunnyvale, CA) has been shown to significantly decreased symptom scores and improve quality of life in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the use of the Stretta procedure in treating patients with recurrent reflux after fundoplication. METHODS: Between March 2002 and December 2003, eight patients with recurrent reflux following ARS underwent the Stretta procedure. All patients were asked to complete an institutional symptom survey pre-Stretta and at 1, 6, and 12 months after the procedure. Patients rated 7 reflux-related symptoms (heartburn, dysphagia, regurgitation, cough, voice changes/hoarseness, asthma, chest pain) on a 0 (none) to 3 (severe) scale. Data were analyzed using a Wilcoxon matched pairs signed rank test where appropriate. RESULTS: Complete data were obtained for seven of the eight patients, with a median follow-up of 253 days (range, 67-378 days). One patient was lost to follow-up and not included in our analysis. Symptom scores decreased significantly, with six patients noting both improved typical and atypical symptoms. Overall, six patients (85%) were satisfied with their results. CONCLUSIONS: Based on this small series, the Stretta procedure significantly reduces subjective symptoms of GERD. The Stretta procedure may serve an important role as an additional management strategy to help manage recurrent GERD after ARS.

Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study.

BACKGROUND: The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) has been well validated as a training device for laparoscopic skills. It has been demonstrated that training to a level of proficiency on the simulator significantly improves operating room performance of laparoscopic cholecystectomy. The purpose of this project was to obtain a national standard of proficiency using the MIST-VR based on the performance of experienced laparoscopic surgeons. METHODS: Surgeons attending the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 2004 Annual Scientific Meeting who had performed more than 100 laparoscopic procedures volunteered to participate. All the subjects completed a demographic questionnaire assessing laparoscopic and MIST-VR experience in the learning center of the SAGES 2004 meeting. Each subject performed two consecutive trials of the MIST-VR Core Skills 1 program at the medium setting. Each trial involved six basic tasks of increasing difficulty: acquire place (AP), transfer place (TP), traversal (TV), withdrawal insert (WI), diathermy task (DT), and manipulate diathermy (MD). Trial 1 was considered a "warm-up," and trial 2 functioned as the test trial proper. Subject performance was scored for time, errors, and economy of instrument movement for each task, and a cumulative total score was calculated. RESULTS: Trial 2 data are expressed as mean time in seconds in Table 2. CONCLUSION: Proficiency levels for laparoscopic skills have now been established on a national scale by experienced laparoscopic surgeons using the MIST-VR simulator. Residency programs, training centers, and practicing surgeons can now use these data as guidelines for performance criterion during MIST-VR skills training.

Construct validation of the ProMIS simulator using a novel laparoscopic suturing task.

BACKGROUND: The use of simulation for minimally invasive surgery (MIS) skills training has many advantages over current traditional methods. One advantage of simulation is that it enables an objective assessment of technical performance. The purpose of this study was to determine whether the ProMIS augmented reality simulator could objectively distinguish between levels of performance skills on a complex laparoscopic suturing task. METHODS: Ten subjects--five laparoscopic experts and five laparoscopic novices--were assessed for baseline perceptual, visio-spatial, and psychomotor abilities using validated tests. After three trials of a novel laparoscopic suturing task were performed on the simulator, measures for time, smoothness of movement, and path distance were analyzed for each trial. Accuracy and errors were evaluated separately by two blinded reviewers to an interrater reliability of >0.8. Comparisons of mean performance measures were made between the two groups using a Mann-Whitney U test. Internal consistency of ProMIS measures was assessed with coefficient alpha. RESULTS: The psychomotor performance of the experts was superior at baseline assessment (p < 0.001). On the laparoscopic suturing task, the experts performed significantly better than the novices across all three trials (p < 0.001). They performed the tasks between three and four times faster (p < 0.0001), had three times shorter instrument path length (p < 0.0001), and had four times greater smoothness of instrument movement (p < 0.009). Experts also showed greater consistency in their performance, as demonstrated by SDs across all measures, which were four times smaller than the novice group. Observed internal consistency of ProMIS measures was high (alpha = 0.95, p < 0.00001). CONCLUSIONS: Preliminary results of construct validation efforts of the ProMIS simulator show that it can distinguish between experts and novices and has promising psychometric properties. The attractive feature of ProMIS is that a wide variety of MIS tasks can be used to train and assess technical skills.

Correlation between perceptual, visuo-spatial, and psychomotor aptitude to duration of training required to reach performance goals on the MIST-VR surgical simulator.

Given the dynamic nature of modern surgical education, determining factors that may improve the efficiency of laparoscopic training is warranted. The objective of this study was to analyze whether perceptual, visuo-spatial, or psychomotor aptitude are related to the amount of training required to reach specific performance-based goals on a virtual reality surgical simulator. Sixteen MS4 medical students participated in an elective skills course intended to train laparoscopic skills. All were tested for perceptual, visuo-spatial, and psychomotor aptitude using previously validated psychological tests. Training involved as many instructor-guided 1-hour sessions as needed to reach performance goals on a custom designed MIST-VR manipulation-diathermy task (Mentice AB, Gothenberg, Sweden). Thirteen subjects reached performance goals by the end of the course. Two were excluded from analysis due to previous experience with the MIST-VR (total n = 11). Perceptual ability (r = -0.76, P = 0.007) and psychomotor skills (r = 0.62, P = 0.04) significantly correlated with the number of trials required. Visuo-spatial ability did not significantly correlate with training duration. The number of trials required to train subjects to performance goals on the MIST-VR manipulation diathermy task is significantly related to perceptual and psychomotor aptitude.

Tribute to a triad: history of splenic anatomy, physiology, and surgery--part 1.

The spleen is an enigmatic organ with a peculiar anatomy and physiology. Though our understanding of this organ has improved vastly over the years, the spleen continues to produce problems for the surgeon, the hematologist, and the patient. The history of the spleen is full of fables and myths, but it is also full of realities. In the Talmud, the Midrash, and the writings of Hippocrates, Plato, Aristotle, Galen, and several other giants of the past, one can find a lot of Delphian and Byzantine ambiguities. At that time, splenectomy was the art of surgery for many splenic diseases. From antiquity to the Renaissance, efforts were made to study the structure, functions, and anatomy of the spleen. Vesalius questioned Galen; and Malpighi, the founder of microscopic anatomy, gave a sound account of the histology and the physiologic destiny of the spleen. Surgical inquiry gradually became a focal point, yet it was still not clear what purpose the spleen served. It has been within the past 50 years that the most significant advances in the knowledge of the spleen and splenic surgery have been made. The work of Campos Christo in 1962 about the segmental anatomy of the spleen helped surgeons perform a partial splenectomy, thereby avoiding complications of postsplenectomy infection. With the recent successes of laparoscopic splenectomy in selected cases, the future of splenic surgery will undoubtedly bring many more changes.

Hepatic surgery and hepatic surgical anatomy: historical partners in progress.

Whether for hepatic trauma or transplantation, a surgeon's knowledge of hepatic anatomy commonly determines a patient's outcome. The first medically relevant anatomic studies of the liver emerged with the endeavors of Herophilus and Erasistratus between 310 and 280 bc. Yet it was not until after the development of anesthesia and antisepsis that the first formal resections were performed during the late 1800s. After vascular occlusion principles had been developed as a means of successful hemorrhage control, several deliberate attempts were made to repair the liver surgically. Such efforts culminated in the work of Wendel in 1910 when he followed avascular planes during hepatectomy. The functional anatomy of surgery and surgical technique had suddenly joined in an effort to advance the practice, and eventually the efficacy of hepatic surgeons in facilitating the modern era of segmental anatomy extended hepatectomies and transplantation surgery.

The Letton-Q modified Roux-en-Y.

Roux-en-Y enteric diversion is useful for correction of alkaline reflux gastritis consequent to loop gastro-enterostomy, in the treatment of spontaneous enterogastric reflux and esophagitis, and in the configuration of primary peptic ulcer surgery. Construction of the Roux-en-Y, however, may be technically difficult or hazardous and is time consuming. Conversion of a loop gastroenterostomy into Roux-en-Y topology by umbilical tape ligation of the afferent limb and jejunojejunostomy was reported by A. Hamblin Letton in 1978. With the availability of stapling devices, the Letton procedure acquires new significance as an attractive alternative to the classic Roux-en-Y.

Hemodynamic assessment and surgical correction of the kinked internal carotid artery.

A fluid-filled oculoplethysmography (OPG) was used to assess carotid artery flow in 50 patients with symptoms of cerebral ischemia. Based on positioned OPG and angiographic studies, 20 patients had angioplastic procedures. At operation, positional electromagnetic flow measurements were obtained to confirm the preoperative noninvasive findings. Electromagnetic flow reductions were identified in 18 patients with positive preoperative positional OPGs. A high correlation between noninvasive testing data and intraoperative flow measurements suggests that positional OPG testing is helpful in identifying hemodynamically significant kinking of the internal carotid artery.

Hemodynamic assessment and surgical correction of kinking of the internal carotid artery.

Although kinking of the internal carotid artery has been recognized for many years, the surgical significance of this lesion has remained controversial. The present study was designed to identify hemodynamic significance of kinking of the internal carotid artery using a positional testing technique with preoperative and postoperative noninvasive data that were correlated with intraoperative electromagnetic flow measurements to establish operative criteria. A fluid-filled oculoplethysmograph (OPG) was used to assess carotid artery flow in 26 patients with cerebral ischemic symptoms who had angiographic documentation of kinking of the internal carotid artery. OPG testing was done with the patient's head positioned first in the neutral, then in the right and left rotations, and then in extension-flexion positions. Sixteen patients underwent angioplasty. At operation electromagnetic flow measurements of the internal carotid artery were determined in these 16 patients with similar positional maneuvers. A reduction of flow from 30% to 80% was found on positional testing during operation in 14 of these 16, and all 14 of these patients also had abnormal preoperative OPG testing. After angioplasty, effects of position on internal carotid artery flow were eliminated, as proved by electromagnetic flowmeter measurements and by follow-up OPG studies in all 14 patients. The other two patients who had been subjected to surgical correction had no positional effects as documented by electromagnetic flowmeter testing. A high correlation between noninvasive data and operative flow measurements suggests that positional OPG testing is helpful in identifying hemodynamically significant kinking. Symptomatic patients with kinking of the internal carotid artery and abnormal OPG testing may be candidates for corrective surgery.

Thoracic outlet syndrome: a comprehensive evaluation.

Using various modalities, we analyzed 110 patients with thoracic outlet compression syndrome who had extensive evaluation. Nerve conduction velocities and Directional Doppler studies are the most useful adjuncts in diagnosis. Diagnosis and selection of the proper treatment of these patients will be outlined.

Cranial nerve injuring during carotid endarterectomy.

Injury to the greater auricular, hypoglossal and superior laryngeal nerves during carotid endarterectomy is preventable. A knowledge of regional anatomy and the mechanisms of such injury allows prevention of this complication. Unilateral individual nerve injury is generally well tolerated, but bilateral or combined nerve injuries can pose a serious threat to life. Minor modifications in technique aid greatly in avoiding nerve injury.