Endoscopic surgery suturing techniques: a randomized study on learning.

BACKGROUND: Surgeons have widely adopted endoscopic suturing techniques using conventional laparoscopic instruments and the more advanced robotic systems. The FlexDex is a novel articulating laparoscopic needle driver providing enhanced dexterity in laparoscopic surgery. This study evaluates and compares the learning curve of endoscopic suturing with conventional laparoscopy, the FlexDex and robotic suturing in novices. METHODS: Participants performed a minimal invasive suturing task in three different ways in a randomized order: with a conventional laparoscopic needle driver, using the FlexDex needle driver and third, using the Da Vinci Si surgical system. Primary outcome was suturing task time. Secondary outcome parameters were assessment of suturing quality and workload perception. RESULTS: A total of 10 novice participants were included and completed a total of 300 sessions. Median (IQR) suturing time of the first 5 sessions was 231 s (188-291) in the laparoscopic group versus 378 s (282-471) in the FlexDex group versus 189 s (160-247) in the DaVinci Si group. The last 5 sessions showed significant reduction of median suturing time of 143 s (120-190), 232 s (180-265) and 172 s (134-199) respectively. Analysis identified that the learning curve for the laparoscopic needle driver and Da Vinci Si was reached in 5 sessions, compared to 8 sessions for the Flexdex. The laparoscopic needle driver and Da Vinci Si showed a significant shorter median suturing time compared to the FlexDex (p = 0.00). The FlexDex quality assessment scores were significantly lower compared to the laparoscopic (p = 0.00) and robotic (p = 0.00) scores and perceived workload remains high for the FlexDex users. CONCLUSIONS: Ex vivo endoscopic suturing with the FlexDex demonstrated a prolonged learning curve compared to laparoscopic and robotic suturing. The learning curve of the FlexDex is fundamentally different from conventional laparoscopic and robotic instruments. This study provides further insights in the implementation and training of endoscopic suturing techniques.

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis.

BACKGROUND: Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material. METHODS: A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment. RESULTS: Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0-0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5-1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0-15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3-8.1) and 5.8% (95% CI 2.9-9.6), respectively. The clinical and statistical heterogeneity was high. CONCLUSIONS: No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

Management of patients with rectal prolapse: the 2017 Dutch guidelines.

BACKGROUND: Rectal prolapse-both external rectal prolapse and internal rectal prolapse-is a disabling condition. In view of the overwhelming number of surgical procedures described for the treatment of rectal prolapse, a comprehensive update concerning the diagnostic and therapeutic pathway for this condition is required to draw recommendations for clinical practice. This initiative was commissioned by the Dutch Association for Surgery (Nederlandse Vereniging voor Heelkunde) as a multidisciplinary collaboration. METHODS: Nine questions outlining the diagnostic approach, conservative and surgical management of rectal prolapse were selected. A systematic literature search for evidence was then conducted in the Medline and Embase databases. RESULTS: Recommendations included diagnostic approach, methods to assess complaints of fecal incontinence and/or obstructive defecation and treatment options, both conservative and surgical. A level of evidence was assigned to each statement following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. CONCLUSIONS: These guidelines for clinical practice are useful in the diagnosis and treatment of rectal prolapse. There are many statements requiring a higher level of evidence due to a lack of studies.

[A girl with abdominal pain and haematomas on the belly]. / Een meisje met buikpijn en hematomen op de buik.

A 14-year-old girl with anorexia nervosa was referred to our paediatric hospital. She had a five-day history of severe abdominal pain. On abdominal sonography and MRI a duodenal wall hematoma was seen, correlating anatomically to abdominal bruises found on physical examination. The girl admitted to self-injury related to her eating disorder.