Objective assessment of skills acquisition during laparoscopic surgery courses.

BACKGROUND: The aim of this prospective study is to objectively assess the acquisition of skills of trainees attending laparoscopic surgery courses. METHODS: Thirty-four junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate runs of 3-day core skills in laparoscopic surgery course. Nine control trainees were also included who did not attend the course. Three virtual tasks (camera navigation, hand-eye coordination, and 2-handed maneuver) were used from a virtual reality simulator (Simbionix) for assessment. Camera navigation was assessed by completion time and maintenance of horizontal view, whereas the other 2 tasks were assessed by completion time, path length (both hands), and the number of movements (both hands). A composite score of overall performance was calculated by combining all the 12 parameters. RESULTS: The course significantly (P < 0.001) improved 91% of the junior trainees' precourse laparoscopic skills. Around 70% to 85% of the participants had improvement in skills in all the parameters following the course. The significant improvements were seen in 10 out of 12 task-specific parameters (P ≤ .004) except path length of the left hand. No significant improvement in skills was seen in any 1 of the 12 parameters for the control participants except for a slight reduction in performance matrics. Foundation and core trainees had acquired significantly (P = .02) more skills (23% improvement) than the specialist trainees (8% improvement). Overall acquired skills did not differ significantly in terms of age, sex, or dominant hand of trainees. CONCLUSION: Objective validated methods can be used to demonstrate course efficacy in addition to providing participants with an insight into their skills. Junior trainees with little or no previous experience benefit the most from such courses irrespective of their age, sex, and dominant hand.

Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography (ERCP) for Bile Duct Stones After Roux-en-Y-Gastric Bypass: Single-Centre Experience.

PURPOSE: Gallstones are common in bariatric patients due to obesity and rapid weight loss. Bile duct stones after Roux-en-Y gastric bypass (RYGB) pose a technical challenge. We present our experience in management of bile duct stones following RYGB using laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP). MATERIALS AND METHODS: Retrospective review of RYGB patients who had endoscopic intervention for bile duct stones between 2010 and 2019. We assessed demographic and clinical outcomes. RESULTS: There were 12 patients: 9 females, median age 64 years (range 34-73), median ASA score 3 (range 2-3), and median body mass index (BMI) 30 kg/m2 (range 24.4-46). Median time of presentation since RYGB was 5 years (range 6-96 months). Clinical presentations were biliary pain with deranged liver function tests (n = 8, 67%) and cholangitis (n = 4, 33%). Ten patients (83%) had cholecystectomy prior to presentation. LA-ERCP was performed in all 12 patients. It was successful in 10 patients (83%) of which 7 were performed as a primary intervention for bile duct stones and 3 were for residual stones following previous bile duct exploration. Two out of 12 LA-ERCPs (17%) were converted to open duct clearance. Median overall hospital stay was 2.5 days (range 1-10). One patient developed post-ERCP pancreatitis; one had chronic pain. There was no major complication or mortality. CONCLUSION: LA-ERCP is feasible for bile duct stones after RYGB and can clear the duct primarily or following previous surgical exploration. It also provides an opportunity to perform cholecystectomy and diagnostic laparoscopy.

Isolated duodenal rupture: primary repair without diversion; is it safe? Review of literature.

Isolated duodenal rupture is a rare injury encountered among children following blunt abdominal trauma. Early diagnosis and treatment are essential to decrease the associated morbidity and mortality. The debate is about the optimum operative management. We report a 6-year-old child who presented with acute abdominal pain due to isolated duodenal injury following blunt abdominal trauma. Emergency laparotomy revealed duodenal rupture at the junction of the first and second part of duodenum and absence of any other visceral injuries. The duodenal injury was defined as grade III, that is, involving 75% of the circumference. We opted to perform primary repair of the injured duodenum in two layers alone without diversion. The abdominal cavity was drained using an open system drain next to the repair. Nasogastric and jejunostomy tubes were used postoperatively for gastric decompression and enteral feeding, respectively. The child had an uneventful recovery, was discharged well on the 10th postoperative day and no stenosis was found on long-term follow-up. The debate was whether to repair the defect primarily or to combine the repair with diversion. Early diagnosis, the isolated nature of the duodenal injury and the possibility of minimal contamination favoured primary repair of the defect without diversion. The good outcome attributed to these factors were in agreement with most of the literature.

Hodgkin's lymphoma presents as an inguinal abscess: a case report and literature review.

Lymphadenitis with suppuration is a rare presentation of Hodgkin's lymphoma with few cases reported in the literature. We report two cases of Hodgkin's lymphoma in two male members of the same family. They presented initially with clinical features suggesting infective inguinal lymphadenitis and then the picture was indistinguishable from inguinal abscess. The diagnosis was made after drainage of the pus and excision of the involved lymph node. The histopathology of the excised lymph node showed Hodgkin's lymphoma-nodular sclerosis for both brothers. After careful staging of both patients, the disease found to be localised to the inguinal group of lymph nodes. The patients referred to the haematologist for chemotherapy and they recovered after treatment.